Original Article: Counseling Patients About Prostate Cancer Screening [Editorial]
Issue Date: October 15, 2018
See additional reader comments at: https://www.aafp.org/afp/2018/1015/p478.html
To the Editor: In their editorial, Drs. Stevermer and Fink presented the American Academy of Family Physicians' (AAFP) clinical preventive services recommendation against adoption of the new U.S. Preventive Services Task Force (USPSTF) guidelines for prostate cancer screening1; however, the editorial does not provide clear direction for physicians to apply this new information. The ambiguity can be particularly challenging for resident physicians who are learning to negotiate the equivocal informational environment of competing guidelines.
The AAFP recommendation indicates that physicians should rely on patients to introduce the topic of prostate cancer screening in the clinical encounter. This requires patients to be informed, assertive, and confident communicators. We know, however, that many men are sometimes reluctant to disclose information to their physicians.2 This also introduces a bias against black men who, though they experience a higher incidence of prostate cancer, are reported to have lower rates of health literacy and patient activation,3 which are two characteristics that predict whether patients volunteer concerns to their physician.
The editorial states that “the AAFP supports providing PSA [prostate-specific antigen]-based screening to men 55 to 69 years of age who express a clear preference for the test after having an opportunity to participate in shared decision making.” Shared decision-making includes three steps: introducing choice, describing options, and helping patients to explore preferences and to make decisions.4 Under this recommendation, how do physicians discern a patient's desire to engage in shared decision-making without first introducing the concept of choice? When patients are not informed, they are not as capable of thinking about what is important to them.4
The risk in this position is that when patients have not been prompted to communicate potential prostate screening concerns, the physician will interpret silence as assent. The physician who chooses to not mention screening may leave patients with unvoiced concerns, unmet informational needs, and frustration with the system. Incorporating decision aids can improve patients' decision-making about prostate cancer screening, without increasing actual screening rates, and simultaneously reduce decisional conflict up to 13 months later.5 By reducing decisional conflict, a single shared decision-making conversation may impact this decision that men face annually for up to 30 years.5
Considering these issues, we are left questioning the way in which to implement this recommendation. From a medical and ethical viewpoint, how do family physicians know when to introduce the subject of prostate cancer screening and when to rely on the patient to introduce the topic?
In Reply: We appreciate the thoughtful comments from Drs. Ledford and Seehusen regarding the application of the AAFP's new recommendations on screening for prostate cancer.1 We agree this is a challenging topic and suspect that it will remain controversial for the foreseeable future.
The USPSTF guidance suggests that physicians should have a shared decision-making discussion with all men age 55 to 69 years2; however, we do not agree that the balance of benefit and harm warranted universal counseling, which may impose significant opportunity costs by diverting time from higher priority preventive services. The 2018 USPSTF recommendation was based on an estimated screening benefit of prostate cancer mortality reduction of 1.3 per 1,000 men screened.1 The previous USPSTF recommendation discouraged prostate cancer screening based on an estimated prostate cancer mortality reduction of 0.9 per 1,000 men screened.3 This increased benefit estimate was derived from only one of the four large randomized clinical trials evaluating screening; the other three found no difference. Overall, the evidence suggests, at best, a small mortality benefit from prostate-specific antigen–based prostate cancer screening, with a significant risk for nontrivial harms to patients who undergo screening. As stated in our editorial, the AAFP recognizes the importance of providing patient-centered care, incorporating patient values in decision-making, and respecting patient choice. In an established doctor-patient relationship, physicians often have a good sense of a patient's values.
We agree that the onus for this decision should not be on the patient. One purpose of the AAFP's recommendation is to ensure that all men who receive prostate-specific antigen–based screening are properly informed about the risks beforehand.1 The wording of the AAFP's recommendation allows physicians a range of options in their approach and discourages setting a universal standard of required counseling.
The incidence and mortality of prostate cancer are higher in black men and men with a family history of prostate cancer, and we agree that prostate cancer screening is a particularly vexing challenge for these men. Men at higher risk may perceive a greater net benefit from screening; however, there are inadequate data from clinical studies to know the balance of benefit and harm of screening in these populations. This is an area we believe merits further research.