Perceptions of Prostate Cancer Screening Controversy and Informed Decision Making: Implications for Development of a Targeted Decision Aid for Unaffected Male First-Degree Relatives

Protocol paper for an implementation science approach to promoting colorectal cancer screening in Federally Qualified Health Center clinics: A stepped-wedge, multilevel intervention trial

Background

Colorectal cancer is the third leading cause of cancer-related deaths in the United States. Despite the Healthy People 2030 goal of 70.5%, colorectal cancer (CRC) screening rates in Federally Qualified Health Centers (FQHCs) are suboptimal at about 40%. The Colorectal Cancer Awareness, Research, Education and Screening-Rural Expansion, Access, and Capacity for Health (CARES-REACH) study seeks to address this disparity and accelerate the adoption and utilization of effective, evidence-based CRC screening practices. This paper describes the CARES-REACH study design and implementation methods.

Methods

Informed by a community-based participatory research (CBPR) framework and enriched by implementation science approaches, CARES-REACH features a stepped wedge design with extension for maintenance to support an implementation strategy focused on multiple levels: organizational, provider, and patient levels that entail processes to boost initial and repeat screening among average risk and age-eligible adults. This multilevel study entails the implementation of a core set of evidence-based interventions (EBIs) that include low literacy patient education (English, Spanish, and Haitian Creole language); provider education, system-wide electronic medical record (EMR) tools including provider prompts and patient reminders, FIT (fecal immunochemical test) kit distribution, plus an organization-wide cancer control champion who motivates providers, coaches and navigates patients, and monitors system-wide CRC screening activities.

Trial registration

NCT04464668.

Patient Communication Preferences for Prostate Cancer Screening Discussions: A Scoping Review

PURPOSE

Prostate cancer screening guidelines have changed as new evidence showing an equivocal mortality benefit led many organizations to relax recommendations for this screening and instead suggest shared decision making. Presently, it is unknown how successfully these conversations happen. Our objective was to understand men's communication preferences when they discuss prostate cancer screening.

METHODS

In this scoping review, we searched 4 electronic databases (Medline, Embase, PsycINFO, and CINAHL) and the gray literature. Additional studies were obtained from reference lists of included studies and relevant review articles. We included qualitative studies reporting patient perspectives relevant to the research question and published in English. Two independent researchers screened titles and abstracts based on these criteria, conducted a full-text review for final inclusion, evaluated the remaining articles for validity, extracted data, and used thematic analysis to build a thematic framework. A subgroup analysis was performed for Black men as many studies elicited their perspectives.

RESULTS

Analyses were based on 29 studies. We identified 4 main themes that men described as critical for successful prostate cancer screening risk discussions with their primary care clinician: using everyday language, receiving a sufficient quantity of information, spending enough time, and having a trusting and respectful relationship. Three additional themes emerged that prohibited men from having any discussions at all: having already decided to pursue prostate cancer screening, being passive in medical encounters, and perceiving threat to one's well-being. Black men faced racism, which impacted medical interactions.

CONCLUSIONS

Our findings point to strategies to support men's communication preferences and address preconceptions surrounding prostate cancer screening. More studies are needed in certain underrepresented populations given the propensity for disparity in health outcomes.

Benefits and Harms of Hepatocellular Carcinoma Surveillance in a Prospective Cohort of Patients With Cirrhosis

BACKGROUND & AIMS

The value of a cancer screening programs is defined by its balance of benefits and harms; however, there are few data evaluating both attributes for hepatocellular carcinoma (HCC) surveillance. We aimed to characterize benefits and harms of HCC surveillance in a large prospective cohort of patients with cirrhosis.

METHODS

We conducted a secondary analysis of a clinical trial evaluating HCC surveillance among patients with cirrhosis at a safety-net health system enrolled between December 2014 and July 2015. We quantified surveillance-related benefits, defined as early HCC detection and curative treatment receipt, and physical harms, defined as diagnostic procedures for false positive or indeterminate results, over an 18-month period.

RESULTS

Of 614 cirrhosis patients with ≥1 surveillance exam, abnormal results were observed in 118 (19.2%) patients. Twenty-six patients developed HCC during follow-up, of whom 16 (61.5%) were detected by surveillance. The proportion of HCC detected at BCLC stage 0/A (62.5% vs 50%, p = .69) and who underwent curative treatment (43.8% vs. 40.0%, p = 1.0) did not significantly differ between surveillance-detected patients and those diagnosed incidentally/symptomatically. Physical harms were observed in 54 (8.8%) patients who underwent surveillance - most of mild severity with only 1 diagnostic CT or MRI and none undergoing invasive testing such as biopsy. Incidental findings on follow-up imaging were found in 40 (6.5%) patients -23 of low clinical importance and 17 medium clinical importance.

CONCLUSIONS

In our cohort of patients with cirrhosis, HCC surveillance was associated with high early tumor detection and minimal physical harms.

Predictors of annual prostate-specific antigen (PSA) screening among black men: results from an urban community-based prostate cancer screening program

BACKGROUND AND OBJECTIVE

Black men have an increased risk of prostate cancer mortality compared with any racial or ethnic group. Further, research on prostate cancer prevention and control messaging focusing on Black men is limited. Community screening events are successful in attracting members from high-risk groups, like Black men, and are a valuable source to collect cancer screening and health promotion data. Therefore, the authors examined data of Black men attending a community-based PCa screening event to evaluate predictors of annual PCa screening, and identify sub-populations of Black men needing targeted cancer prevention messaging.

METHODS

Black men attending PCa screening events in St. Louis, MO 2007-2017 were eligible. Participants completed either a mail-in or on-site survey at the time of their screening to collect information on annual screening history. We analyzed sociodemographic factors, having a first-degree relative with a history of PCa, healthcare utilization characteristics, and predictors of annual PSA screening. Logistic regression analysis was used to assess the association between predictors and annual PSA screening.

RESULTS

Data was analyzed from 447 respondents. One-third of the residents did not know their cancer family history status. Older age and having a primary healthcare provider predicted an annual prostate cancer after attending the PCa community screening event. In the fully adjusted model, all ages older than 45 years were 2-4 times more likely to have an annual PCa screening. Having a healthcare provider also predicted an annual PCa screening (OR: 4.59, 95% CI: 2.30-9.14).

CONCLUSION

Regardless of sociodemographic and family history factors, older Black men and those with a primary physician are more likely to have an annual PSA screening. Cancer prevention promotion efforts for Black men should target mechanisms that facilitate family cancer history conversations to engage younger Black men. Also, additional health promotions efforts are needed to educate Black men without a primary healthcare provider.

Exploring Prostate Cancer Patients' Interest and Preferences for Receiving Genetic Risk Information About Cancer Aggressiveness

The number of cases of aggressive prostate cancer is increasing. Differentiating between aggressive and indolent cases has resulted in increased difficulty for the physician and patient to decide on the best treatment option. Due to this challenge, efforts are underway to profile genetic risk for prostate cancer aggressiveness, which may help physicians and patients at risk for developing aggressive prostate cancer to select an appropriate treatment option. This study explores patients’ interest in receiving genetic results, preference for how genetic risk information should be communicated, and willingness to share results with adult male first-degree relatives (FDRs). A nine-item survey was adapted to assess their beliefs and attitudes about genetic testing for prostate cancer aggressiveness. In addition, participants (n = 50) responded to hypothetical scenarios and questions associated with perceived importance of risk disclosure, preferences for receiving genetic risk information, and sharing of results with FDRs. As the hypothetical risk estimate for aggressive prostate cancer increased, patients’ willingness to receive genetic risk information increased. This study found that most patients preferred receiving genetic risk education in the form of a DVD (76%), one-page informational sheet (75%), or educational booklet (70%). Almost all patients (98%) reported that they would be willing to share their test results with FDRs. The results of this study highlight prostate cancer patients’ desire to receive and share genetic risk information. Future research should focus on assessing the long-term benefits of receiving genetic information for prostate cancer patients and implications of sharing this information with FDRs.

An Exploration of Precancer and Post-Cancer Diagnosis and Health Communication Among African American Prostate Cancer Survivors and Their Families

Prostate cancer is the second most common cancer among American men, with Black men at the highest risk for the disease. Few studies have been published on how communication between Black prostate cancer survivors and their family members affect health outcomes and subsequent health communication. The purpose of this study was to understand cancer and health communication among Black prostate cancer survivors and their families before and after disclosing their diagnosis. Through a mixed method design, 11 Black prostate cancer survivors participated from the Southeastern region of the United States, completed questionnaires, and took part in a focus group. The study utilized 4 focus groups of Black prostate cancer survivors ranging in age from 51 to 76 years. Descriptive statistics revealed 91% (n = 10) of participants indicated they could openly discuss health issues in their family and 82% (n = 9) indicated a female relative as the person responsible for teaching about health. An analysis of the transcripts revealed four themes utilizing thematic network: (a) communication over the life course of the prostate cancer survivor, (b) parents’ communication with family, (c) disclosing prostate cancer diagnosis, and (d) treatment options for prostate cancer. Results suggested the participants recognized the importance of discussing prostate cancer with their families to reduce fears and misconceptions about the disease. Through the exploration of cancer and health communication within Black families, solutions can be derived for increasing health behaviors and health knowledge among men.

Men's perspectives of prostate cancer screening: A systematic review of qualitative studies

Background

Prostate cancer is the most commonly diagnosed non-skin cancer in men. Screening for prostate cancer is widely accepted; however concerns regarding the harms outweighing the benefits of screening exist. Although patient’s play a pivotal role in the decision making process, men may not be aware of the controversies regarding prostate cancer screening. Therefore we aimed to describe men’s attitudes, beliefs and experiences of prostate cancer screening.

Methods

Systematic review and thematic synthesis of qualitative studies on men’s perspectives of prostate cancer screening. Electronic databases and reference lists were searched to October 2016.

Findings

Sixty studies involving 3,029 men aged from 18–89 years, who had been screened for prostate cancer by Prostate Specific Antigen (PSA) or Digital Rectal Examination (DRE) and not screened, across eight countries were included. Five themes were identified: Social prompting (trusting professional opinion, motivation from family and friends, proximity and prominence of cancer); gaining decisional confidence (overcoming fears, survival imperative, peace of mind, mental preparation, prioritising wellbeing); preserving masculinity (bodily invasion, losing sexuality, threatening manhood, medical avoidance); avoiding the unknown and uncertainties (taboo of cancer-related death, lacking tangible cause, physiological and symptomatic obscurity, ambiguity of the procedure, confusing controversies); and prohibitive costs.

Conclusions

Men are willing to participate in prostate cancer screening to prevent cancer and gain reassurance about their health, particularly when supported or prompted by their social networks or healthcare providers. However, to do so they needed to mentally overcome fears of losing their masculinity and accept the intrusiveness of screening, the ambiguities about the necessity and the potential for substantial costs. Addressing the concerns and priorities of men may facilitate informed decisions about prostate cancer screening and improve patient satisfaction and outcomes.

Similar perspectives on prostate cancer screening value and new guidelines across patient demographic and PSA level subgroups: A qualitative study

BACKGROUND

In 2012, the United States Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA)-based prostate cancer screening for all men.

OBJECTIVE

To inform educational materials addressing patient questions and concerns about the 2012 USPSTF guidelines, we sought to: (i) characterize patient perceptions about prostate cancer screening benefits, harms and recommendations against screening, and (ii) compare perceptions across race, age and PSA level subgroups.

METHODS

We conducted qualitative interviews with a sample of 26 men from the Minneapolis Veterans Affairs Health Care System, stratified by race (African American, other), age (50-69, 70-84) and PSA level (documented PSA level ≥4 in Veterans Health Administration electronic medical records vs no such documentation). We used an inductive approach informed by grounded theory to analyse transcribed interviews.

RESULTS

Most men in all subgroups expressed misperceptions about the benefits of prostate cancer screening and had difficulty identifying harms associated with screening. In all subgroups, reactions to recommendations against screening ranged from unconditionally receptive to highly resistant. Some men in every subgroup initially resistant to the idea said they would accept a recommendation to discontinue screening from their provider.

CONCLUSIONS

Given the similarity of perceptions and reactions across subgroups, materials targeted by race, age and PSA level may not be necessary. Efforts to inform decision making about prostate cancer screening should address misperceptions about benefits and lack of awareness of harms. Provider perspectives and recommendations may play a pivotal role in shaping patient reactions to new guidelines.

What's new in screening in 2015?

PURPOSE OF REVIEW

The aim of this review was to highlight important articles in the field of prostate cancer screening published during 2015 and early 2016. Four major areas were identified for the purpose: screening strategies, post-United States Preventive Services Task Force (USPSTF) 2011-2012, screening trends/patterns, and shared decision making.

RECENT FINDINGS

Several studies furthered the evidence that screening reduces the risk of metastasis and death from prostate cancer. Multiplex screening strategies are of proven benefit; genetics and MRI need further evaluation. Prostate-specific antigen (PSA) screening rates declined in men above age of 50 years, as did the overall prostate cancer incidence following the USPSTF 2011-2012 recommendation against PSA. The consequences of declining screening rates will become apparent in the next few years. More research is needed to identify the most optimal approach to engage in, and implement, an effective shared decision-making in clinical practice.

SUMMARY

Data emerging in 2015 provided evidence on the question of how best to screen and brought more steps in the right direction of 'next-generation prostate cancer screening'. Screening is an ongoing process in all men regardless of whether or not they might benefit from early detection and treatment. After the USPSTF 2011-2012 recommendation, the rates of PSA testing are declining; however, this decline is observed in all men and not solely in those who will not benefit from the screening. The long-term effect of this recommendation might not be as anticipated. More studies are needed on how to implement the best available evidence on who, and when, to screen in clinical practice.

Informed decision making among first-degree relatives of prostate cancer survivors: a pilot randomized trial

BACKGROUND

First degree relatives (FDRs) of men diagnosed with prostate cancer (PCa) are at increased risk for developing the disease, due in part to multiple concurrent risk factors. There is a lack of innovative targeted decision aids to help FDRs make an informed decision about whether or not to undergo PCa screening.

PURPOSE

This randomized pilot trial evaluated the efficacy of a targeted PCa screening decision aid in unaffected FDRs of PCa survivors.

METHODS

Seventy-eight Black and White FDRs were randomized to one of two decision aid groups; 39 to a FDR-targeted decision aid and 39 to a general decision aid. The targeted decision aid group received a general PCa decision aid booklet plus a newly developed decision aid DVD targeted specifically for FDRs. PCa screening decision outcomes included knowledge, decisional conflict, distress, and satisfaction with screening decision. Outcomes were assessed at baseline and 4 weeks after baseline.

RESULTS

There were no differences by intervention group for knowledge, decisional conflict, distress, or satisfaction with screening decision (p>0.05). However, men in both groups had significant increases in knowledge and decreases in decisional conflict (p<0.001). These changes were most pronounced (p<0.05) for younger men compared to older men.

CONCLUSION

Results suggest that general and targeted information can play an important role in increasing knowledge and decreasing decisional conflict among FDRs. Additional research is needed to identify subgroups of men who benefit the most and better understand the outcomes of a screening decision aid among diverse samples of FDRs.