to the editor: I first want to compliment Dr. Spann on a well-written editorial1 regarding prostate cancer, a topic that is rife with controversy, subspecialist and specialty society (e.g., American Cancer Society) bias, and incomplete information. I recommend that family physicians read this editorial, along with the companion “Special Medical Report.”2
My only point of disagreement is with the author's last paragraph and particularly the last sentence, where it is advised that prostate cancer screening is the patient's choice after being “carefully informed” by the physician. My concern is that this editorial takes three pages to explore the controversies regarding screening, and the companion piece (Special Medical Report) is a two-page summary of a three-article guideline—and all of this information is supposed to be “carefully” explained so that the patient can make an informed choice.
It would appear that physicians are having a hard time understanding and making a decision on this topic; is it fair or realistic to expect the patient to be able to make a truly informed choice? Physicians have a hard enough time analyzing statistics, let alone the layman! How many physicians know that it will take a 10- to 15-year study involving several hundred thousand men to demonstrate prospectively that screening actually reduces mortality, weeding out the various biases that Dr. Spann nicely discusses?3 How often are physicians misled by either the “snails” or the “evangelists,” who come to opposite conclusions on studying the same data?4
I think this is an issue in which the family physician needs to draw the line, saying, “This is what I do, based on my study of the currently available literature. To do more (or less) is just not something I can currently defend.” Or, as I tell my patients, “This is what I would do for my dad/granddad.” Patients seem to listen to and respect this approach. Often, the patient has a strong preconception and won't listen or is dazed when I have attempted to carefully explain the more than myriad hypotheses, interpretations and facts.
in reply: Dr. Smith raises a very important issue regarding the implementation of evidence-based clinical practice guidelines that incorporate the patient's values or preferences into the decision process: How does a busy physician discuss all of the benefits, risks and costs of a given medical intervention with the patient during a brief clinical encounter in enough detail to allow that patient to make a truly informed decision?
This dilemma is not unique to the issue of prostate cancer screening; it is common to many of the preventive and therapeutic interventions that we offer to our patients on a daily basis. Eddy1 asserts that clinical practice guidelines should incorporate the patient's preferences or values in the decision-making process. Lee2 states that patients must give informed consent before participating in a screening program, insisting that physicians should “match the appropriate level of screening with each patient's unique attitude toward the risks of disease and the risks associated with the screening procedure.” He goes on to state that, as physicians, “our duty is to give these patients the best data available, untainted by our personal feelings or symbolism, and let them plug these numbers into their own value systems.”
The physician must, in my opinion, be careful not to interject his or her own biases or values into the patient's decision-making process. To do so risks interfering with the patient's autonomy and verges on paternalism. The real challenge, though, is to communicate to the patient all of the information he needs to make a truly informed choice. Physicians need practical tools to be able to do this in a busy practice setting. One approach is to develop a brief, written “balance sheet,” which lists in simple language the risks, benefits and costs of the intervention. Hahn and Roberts3 have developed such a balance sheet for prostate cancer screening.
Another approach is to develop a videotape that educates the patient about the different choices. Such an educational videotape was used by Flood and colleagues4 in a study that evaluated the impact of viewing a videotape about prostate-specific antigen (PSA) testing on patients' knowledge about prostate cancer screening and treatment, and their decision to undergo PSA testing. Men who reviewed the videotape were found to better informed about PSA tests and were less likely to undergo screening for prostate cancer.4
Volk and colleagues conducted a similar study using the videotape “The PSA Decision: What YOU Should Know,” produced by the Foundation for Informed Medical Decision Making, of Hanover, N.H. Results of the study showed that men who reviewed the videotape were more knowledgeable about prostate cancer screening and less likely to choose to be screened for prostate cancer than men who did not watch the videotape (unpublished data).
Another option is for the physician to become very familiar with all of the issues important to the decision, and to present these issues to patients in a conversational fashion, as suggested by Marshall.5 This approach requires that the physician memorize the facts and practice communicating them verbally in an understandable and efficient manner.
The difficulty of the task should not dissuade us from carefully educating our patients about their choices so that they can make truly informed decisions. The development of simple and practical tools to communicate benefits, risks and costs to patients and elicit their preferences or values for incorporation into medical decisions in an efficient manner remains an important research challenge for family medicine.