Prostate screening often occurs without discussion of benefits, risks

March 28, 2017

A new study finds that while a blood test that helps to screen for prostate cancer remains common, only 30 percent of men in a large national survey reported having a balanced discussion of the advantages and disadvantages of the screening with their doctor. Moreover, having such a discussion of both pros and cons has become less likely since the U.S. Preventive Services Task Force issued a recommendation against performing prostate-specific antigen (PSA) testing in 2012.

"That only about a third of patients reported having a discussion of advantages and disadvantages is an alarming statistic," said study lead author Dr. George Turini III, clinical instructor in medical science at the Warren Alpert Medical School of Brown University and a urologist with the Southcoast Physician Group.

Co-author Dr. Joseph Renzulli, associate professor of surgery and a urologist at the Minimally Invasive Urology Institute at Miriam Hospital, added, "The concept of 'shared decision making' for prostate cancer screening is not occurring in the community."

For example, in 2014 out of a sample of 111,241 men who responded to the national Behavioral Risk Factor Surveillance System survey, 29.5 percent reported discussing both advantages and disadvantages, 33.9 percent discussed neither, 35.7 percent reported discussing only advantages of PSA, and 0.8 percent reported discussing only disadvantages. In data from 2012, before the task force made its recommendation against the test, out of 105,812 men who responded to the survey, 30.1 percent discussed both, 30.5 percent discussed neither, 38.5 percent discussed only advantages, and 0.8 percent discussed only disadvantages.

Meanwhile, 63.0 percent of the men in 2012 had PSA tests, as did 62.4 percent of the men in 2014, according to the study published online in the journal Urology. In each year thousands of men had the test without having a discussion of how it could either benefit them, for instance via early detection of cancer, or lead to unnecessary adversity, such as a side effects from biopsy or unneeded treatment. They either got no information or only one side of the story.

In addition, the researchers found, men who have low incomes, did not finish high school, lack insurance, or are Hispanic were significantly less likely than men overall to report hearing about the pros and cons of screening via the PSA test, the study found.

"The most vulnerable men are getting less counseling," said co-author Annie Gjelsvik, assistant professor of epidemiology in the Brown University School of Public Health.

A controversial topic

The PSA test reveals blood levels of a protein naturally secreted by the prostate. Levels could become elevated for a number of reasons including the normal enlargement of the prostate as men age, Turini said. But cancer could also elevate them.

When the task force in 2012 discouraged PSA testing, Turini said, it was because there are risks to what follows from screening. If cancer is suspected, it can only be confirmed with a biopsy and that could cause problems such as infection, bleeding or discomfort.

Beyond those concerns, if prostate cancer is confirmed, the risks inherent in treatment options such as surgery, radiation or hormonal alteration, can be "truly life altering," he said.

"In some cases, a low volume of less aggressive prostate cancer may not necessitate treatment, but even in those cases where a 'treatment' is not performed in favor of active surveillance, the emotional distress of a cancer diagnosis shouldn't be underestimated," Turini said.

But whenever a cancer does present a threat to health, there are also clear advantages to catching it early. Therefore many urologists still believe that doctors and their patients should weigh these pros and cons of screening. For that reason, the authors wrote, the American Urologic Association and the American Cancer Society advocate thorough discussion and decision-making between doctors and patients.

The study authors sought to understand the state of those discussions and how the task force recommendation may have changed them. Gjelsvik noted that it's important to measure and track the full spectrum of effects of public health actions, such as the new national recommendations.

The findings could be explained by factors independent of the U.S. Preventive Services Task Force recommendation, the authors acknowledged, but they concluded the paper with this concern: "We believe our findings may be indicative of a shift in practice patterns away from detailed pre-screening discussions among health care providers who have implemented the [USPSTF] recommendation into their care giving. Long-term evaluation of this trend is necessary, particularly to ensure that men who are given an order for a PSA test receive the absolutely necessary counseling required to allow them to appreciate the important consequences associated with the decision to pursue screening."

Amid all the findings of concern, including the overall trend and disparities of income, education, insurance and ethnicity, the researchers did find one bright spot: Black men, who are known to be at higher risk for prostate cancer incidence and death, were more likely to report having discussed advantages and disadvantages than men on average.

Turini said the study suggests that urologists may be able to do more to help their primary care physician colleagues have balanced and informative conversations with their patients. Primary care physicians are increasingly pressed for time with each patient and it can seem easy to order an additional test if blood is going to be drawn for other purposes anyway, Turini said. But the moment when a PSA test comes back with an elevated reading is not the ideal moment to only begin the conversation of what that could mean.

"It's our job in the urology community to make it as easy as possible for the primary care physicians and other general practitioners to comfortably disseminate as complete and balanced information as possible," he said.
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Brown University

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