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Prostate Cancer: Doctors Seldom Discuss Both the Advantages and Disadvantages of the PSA Test With Patients
The PSA test for prostate cancer is controversial. But if you’re an adult male, your doctor should still be discussing it with you.
By Laura Newman
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March 12, 2019
Doctors rarely discuss the pros and cons of getting a prostate-specific antigen (PSA) test to screen for prostate cancer, despite the fact that several physician organizations recommend this practice, according to a study published online March 12 in the journalAnnals of Family Medicine. When the discussion is introduced, according to the study, it’s frequently weighted towards the test’s potential benefits rather than some of its well-known pitfalls, namely over-detection and overtreatment of slow-growing tumors that are not life-threatening.
A Test With Several Caveats
At one time, the PSA test for prostate cancer was considered the male equivalent of the Pap smear, a test capable of detecting early signs of cervical cancer in women. Until 2012, in fact, the PSA was in wide use across the United States as a routine part of the blood tests run during annual physicals for men ages 40 and older.
But controversy began to surround the test as it became apparent that it was not very specific — infections and problems unrelated to prostate cancer can also cause an elevated PSA result, for example — and that it led to overdiagnosis and overtreatment of nonthreatening tumors. Overtreatment is a problem not only because of the psychological and financial burden inherent, but because some of the treatments for prostate cancer can leave men impotent or incontinent.
In 2012, the U.S. Preventive Services Task Force questioned the evidence for the PSA and raised the issue of whether the harms caused by overdiagnosis and overtreatment outweighed the potential benefits. At that time, they recommended against men having PSAs.
Now the U.S. Preventive Services Task Force is moving towards tempering its position; some expect it will soon recommend discussion with men between the ages of 55 and 70, a position similar to that of the American Urological Association.
In recent years, major medical authorities, including the American Cancer Society, the American Urological Association, the American College of Physicians, and others, recommended shared decision-making for PSA testing.
“Shared decision-making is essentially a two-way conversation between the doctor and patient” that addresses the “advantages and disadvantages, and what’s unknown,” with “the patient discussing what their preferences are,” says Ann Goding Sauer, MSPH, co-author of the recent paper and an epidemiologist from the American Cancer Society in Atlanta.
The recent study reveals that shared decision-making is not working as well as proponents hoped.
Related: What a High PSA Level Means if It’s Not Prostate Cancer
Few Men Report Discussing Pros and Cons With Doctor
In the study, researchers looked back at the Centers for Disease Control and Prevention (CDC) National Health Interview Surveys from 2010 and 2015. These surveys included 9,598 insured individuals between ages 50 and 74, the majority of whom were white. Respondents were asked whether the doctor had ever discussed the advantages and disadvantages of the PSA test and whether they were informed that doctors disagree about the benefits of the test.
Among the study’s key findings:
Related: FDA Approves Use of the Prostate Cancer Drug Zytiga Before Hormone Therapy
Making Shared Decision-Making Work
Part of the issue may be the short time frame of many appointments, says Paul Han, MD, senior scientist at Maine Medical Center Research Institute in Scarborough. “Even well-intentioned doctors are finding it tough to take the time in a 10-minute office visit” to include shared decision-making regarding the PSA test. Shared decision-making is not reimbursed either, says Dr. Han.
Han conducted a study, which appeared in August 2013 in the journalAnnals of Family Medicine, on shared decision-making using National Health Interview Survey data in 2010. Han expressed concern that his study found — as the current one did — that the people with low education, low access to care, and poor health literacy, were the least likely to participate in shared decision-making.
“Future researchers need to find better ways to reach this group,” Han says. He recommends providing sufficient time and incentives for clinicians to engage patients in shared decision-making. He also says clinicians may need training “on how to effectively and efficiently engage patients in shared decision-making.
“The technical information used in these conversations needs to be made understandable and easily accessible by clinicians and patients through decision support tools and other strategies.
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