BERKELEY, CA (UroToday.com) - Aside from swaying patient opinions, the recommendation of the United States Preventive Services Task Force (USPSTF) to discontinue routine prostate cancer screening among all men, regardless of age, has changed the practice patterns of primary care providers, and in turn, those of urologists. Population-based studies and anecdotal evidence suggest that prostate cancer screening is on the decline among primary care providers. Routine or opportunistic screening has been replaced by total omission of screening. Consequently, eligible men with other urologic complaints are arriving to clinic either without ever having been screened for prostate cancer or without their annual PSA test. Sadly, in many of these men, neither a discussion of the risk-benefit ratio of prostate cancer screening nor an individualized assessment of the patient’s risks has occurred prior to withholding or discontinuing screening.
The potential long-term population effects of this practice are significant. Recent evidence suggests that while discontinued screening will eliminate over diagnosis entirely, it will fail to prevent two-to-four-thousand avoidable cancer deaths a year. By limiting prostate cancer screening to age-appropriate men and to men at increased risk, over diagnosis can be minimized while preserving the life-saving benefits of screening.
In contrast to the USPSTF, the American Urological Association (AUA) supports a shared decision-making process between the patient and clinician to determine the appropriateness of prostate cancer screening. With patients less likely to be routinely “pre-screened” than in the past, the responsibility for discussing the risks and benefits of prostate cancer screening now rests on the urologist. Unfortunately, in modern-day clinical practice, there is very little time available for this complex discussion amidst a hectic clinic schedule.
From our study, we found that only about half of patients reported a good grasp of the screening recommendations. This suggests that many patients may be unaware that they are no longer being screened for prostate cancer. Furthermore, in the absence of routine screening guidelines, patients may not know enough to ask about their cancer risk or eligibility for prostate cancer screening. After exposing patients to the pros and cons of screening from both the AUA and USPSTF, respectively, we found that patients continued to support prostate cancer screening but formed a greater appreciation for its potential harms. We were able to demonstrate that a well-informed patient population, even without physician guidance, seemed to be better equipped to grasp this complex issue. Although the question is beyond the scope of our research, it will be interesting to see if this approach also assists patients in making this complex decision for themselves.
Decision-making tools that provide fair and balanced information on prostate cancer screening, similar to the ones used in our study, may facilitate future patient discussions on the topic. We believe that pre-visit distribution of prostate cancer screening decision aids, perhaps in the waiting room, may provide the opportunity for shared decision making to realistically occur at the office visit.
Written by:
Matthew J. Maurice, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Resident Physician, PGY6
UH Urology Institute
University Hospitals Case Medical Center
Case Western Reserve University School of Medicine
11100 Euclid Avenue
Cleveland, OH 44106 USA
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