Henry* is a 67-year-old man who was seen by one of our urologists and then referred to me by one of the nurses for help. His PSA was just over 5 ng/ml and the urologist had booked him for a prostate biopsy the following week. Henry had no idea why all of this was happening. He had gone to see his family physician because he needed a refill of his anti-hypertensive medication. The physician he had been seeing over the years had retired and Henry’s appointment was with “Doogie Howser,” according to Henry. I chuckled at that; for many of us, the younger generation of physicians just seem so young…
This physician seemed rushed, according to Henry; he was used to his previous physician who took his time and always chatted for a while about hockey and Henry’s children and grandchildren. “Dr. Doogie” told Henry that he needed to have some tests and sent him to the laboratory downstairs. Henry didn’t think much of this until he received a call from our clinic to inform him of his appointment with the urologist. He attended his appointment at our clinic and was shocked that the appointment was at the local cancer center. Did he have cancer? He waited over an hour in the waiting room, his anxiety growing by the minute. Eventually he was seen by the urologist who told him that his PSA was raised and that he needed a biopsy. Henry didn’t recall much after that. Fortunately my afternoon that day was quiet and I could see him immediately.
Henry did not know that one of the blood tests was a PSA test. He had never had one before and his previous physician had not suggested this, to the best of his recollection. He was confused and angry and did not know what to do. Should he have the biopsy? He wasn’t sure what that meant. Did he have cancer and was he going to die? Why was this happening to him? I took a deep breath and started at the beginning…
I had recently read an article in the Journal of Clinical Oncology in which Faiena et al1 proposed, rightly, that there is no one-size-fits-all approach to PSA screening. They recommend that an individualized strategy with shared decision making between physician and patient is needed. However, the weakness in their argument lies not with their detailed review of the evidence about PSA screening but in the practice of shared decision making.
The evidence to date suggests that as recently as the years 2010 to 2015, there has been no increase in shared decision making and many men (83%) who had PSA screening did not receive the information they would need to make a truly informed decision. Twenty one percent reported being told only the advantages of screening.2 Older evidence states that almost 65% of men did not have a discussion about the risks and benefits of PSA screening.3 In another large national study, just 10% of men received the information they needed to make an informed choice, namely that they had a choice whether to be screened or not, that not all physicians recommend the screening, and that uncertainty exists as to whether PSA screening saves lives.4 It is well established that physician attitude affects the offer of PSA screening to their patients5 and that men are influenced by the recommendation of their physician.6 Not telling the patient that their PSA level is going to be measured, as in the case of Henry, is another matter.
So why is shared decision making not happening? There are numerous barriers including lack of time, competing demands, fears of malpractice, and patient interest,7 as well as perceived level of health literacy of the patient and physician forgetfulness.8 Until physicians take the time to discuss the advantages, disadvantages, and most recent evidence in a way that the man understands—and that discussion is remunerated appropriately—we will continue to see men who have been screened without their knowledge or consent. These men are scared, unsure of what to do next, and not infrequently angered that they were not informed. I see men like Henry every week in my practice and their confusion and suffering is significant and preventable.
*Name and details changed for privacy.
- Faiena I, Holden S, Cooperberg MR, et al. Prostate cancer screening and the Goldilocks principle: how much is just right? J Clin Oncol. 2018;36:937-41.
- Fedewa SA, Gansler T, Smith R, et al. Recent patterns in shared decision making for prostate-specific antigen testing in the United States. Ann Fam Med. 2018;16139-44.
- Han PKJ, Kobrin S, Breen N, et al. National evidence on the use of shared decision making in prostate-specific antigen screening. Ann Fam Med. 2013;11:306-14. doi:10.1370/afm.1539
- Leyva B, Persoskie A, Ottenbacher A, et al. Do men receive information required for shared decision making about PSA testing? Results from a national survey. J Cancer Educ. 2016;31:693-701.
- Hayat Roshanai A, Nordin K, Berglund G. Factors influencing primary care physicians’ decision to order prostate-specific antigen (PSA) test for men without prostate cancer. Acta Oncologica. 2013;52:1602-8.
- Pucheril D, Dalela D, Sammon J, et al. The influence of physician recommendation on prostate-specific antigen screening. Urol Oncol. 2015;33:424.e421-7.
- Davis K, Haisfield L, Dorfman C, et al. Physicians' attitudes about shared decision making for prostate cancer screening. Fam Med. 2011;43:260-6.
- Guerra CE, Jacobs SE, Holmes JH, et al. Are physicians discussing prostate cancer screening with their patients and why or why not? A pilot study. J Gen Intern Med. 2007;22:901-907.