Prostate Cancer – To Screen or Not to Screen, that is a Complex Question

June is international Men’s Health Month.  The aim is to bring awareness to male health issues and promote healthy practices.¹ Today we will explore how tailored education and shared decision-making tools could help men get the most from conversations with healthcare professionals about prostate cancer and facilitate decisions about screening.  Stay tuned for a second post this week focusing on the role of patient-reported outcomes in measuring prostate cancer treatment-related symptoms and how this information may help inform treatment decisions.

What are the benefits and risks of screening for prostate cancer?

Prostate cancer is the second most common cancer affecting men in the United States and one of the leading causes of cancer-related death among men in all racial groups.² Early detection of prostate cancer through screening can facilitate timely treatment that improves outcomes.  However, there are also possible risks, including ‘false positives’ that may cause needless stress, follow-up diagnostic tests that have their own risks, and treatments that may prove to be unnecessary depending on the speed at which an individual’s cancer progresses.³ These complex factors, along with evolving screening recommendations, have led to confusion amongst health care providers (HCPs) and their male patients.^2,3  

What are the recommendations around screening and are these being followed?

Because of this complexity, the U.S. Preventive Services Task Force (USPSTF), American College of Physicians (ACP), and American Urologic Association (AUA) all advise a conversation between HCPs and patients regarding the uncertainties, benefits, and potential harms of prostate cancer screening as well as the patients’ personal preferences and risk factors, before making a decision about screening.^4,5,6 

Despite these guidelines, National US survey data suggests that only 25% of men aged 40 and older discuss PSA screening with their provider.⁵

Why don’t men discuss PSA screening with their HCP?

Research suggests that there are barriers to these discussions, including screening recommendations with poor interpretability.

For example, one study found that only 19.1% of men who were newly diagnosed with prostate cancer were able to accurately identify the meaning of the USPSTF’s screening recommendation. Most of the participants (74.3%) also expressed a lack of confidence that the recommendations were in the best interest of men’s health.⁷ However, men who had paid more attention to the recommendation and had a better understanding of it, held a more nuanced view (i.e., that annual screening should be conducted for some, but not at all men over the age of 50).⁷

Addressing these barriers could facilitate patient-provider discussions, improve informed decision making, and ultimately help prevent morbidity and mortality from prostate cancer. This may include revised screening recommendations presented in clear language, as well as tailored content that addresses the individual’s misconceptions and concerns about screening.

How can shared decision making tools help?

Shared decision-making tools that consider the individual’s needs and preferences as well as the provider’s clinical expertise and limited appointment time could facilitate conversations between male patients and their providers and increase men’s understanding of the potential benefits and harms of screening. ^5,6,7

A team of multi-disciplinary clinicians and researchers have identified three main principles to guide the development of tools to enhance shared decision-making about prostate cancer screening:

• Information presented to the patient must be informed by the best evidence available and avoid statistics that are still in dispute
• The patient should be provided with a clear decision-making framework that avoids the consolidation of multiple scenarios into a single choice
• The schema should be appropriate for all physician types, including primary care physicians and specialists (e.g., urologists).⁶

In addition, the team recommends an “ask-tell-ask” approach in which the “tell” portion (i.e., information shared by the physician and presentation of the “yes or no” screening choice) is informed by what the patient already knows about screening and the individual’s preferences and concerns.⁶  

Where can men get help with making decisions about prostate cancer screening?

 For men looking for additional support in making decisions regarding prostate cancer screening and treatment, interactive tools can be accessed online. These include online modules offered by the Centers for Disease Control and Prevention (CDC):⁸

• https://simulations.kognito.com/PROS/PatientScreening/

• https://simulations.kognito.com/PROS/PatientTreatment/

References

1. Men’s Health Month. International Men’s Health Week.  Accessed June 3, 2022.  https://menshealthmonth.org/imhw/imhw

2. CDC Prostate Cancer. Prostate Cancer Statistics.  Accessed June 10, 2022.  https://www.cdc.gov/cancer/prostate/statistics/index.htm

3. S. Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening.  Accessed June 10, 2022.  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening#fullrecommendationstart

4. Net. Prostate Cancer: Screening.  Accessed June 14, 2022.  https://www.cancer.net/cancer-types/prostate-cancer/screening

5. Bhuyan SS, Chandak A, Gupta N, et al. (2017). Patient-provider communication about prostate cancer screening and treatment: new evidence from the health information national trends survey.  American Journal of Men’s Health, 11(1), 134-146.

6. Vickers AJ, Edwards K, Cooperberg MR & Mushlin AI (2014). A simple schema for informed decision-making about prostate cancer screening.  Annals of Internal Medicine, 161(6), 441-442.

7. Orom H, Underwood W, Homish DL, et al. (2015). Prostate cancer survivors’ beliefs about screening and treatment decision-making experiences in an era of controversy.  Psycho-Oncology, 24(9), 1073-1079.

8. CDC Prostate Cancer. Talk to Nathan.  Accessed June 14, 2022.  https://simulations.kognito.com/PROS/PatientScreening/ ; https://simulations.kognito.com/PROS/PatientTreatment/