I didn't know I'd be commenting so soon on PSA screening. This Week's American Journal of Public Health has an article on men's understandnig of PSA testing:
Objectives. This study examined knowledge about prostate-specific antigen (PSA) screening among African Americans and Whites. Because PSA screening for prostate cancer is controversial, professional organizations recommend informed consent for screening.
Methods. Men (n = 304) attending outpatient clinics were surveyed for their knowledge about and experience with screening. Results. Most men did not know the key facts about screening with PSA. African Americans appeared less knowledgeable than Whites, but these differences were mediated by differences in educational level and experience with prostate cancer screening.
Conclusions. Public health efforts to improve informed consent for prostate cancer screening should focus on highlighting the key facts and developing different approaches for men at different levels of formal education and prior experience with screening.
The study made headlines in the Reuters Health News this week:
A number of prominent groups, including the U.S. Preventive Services Task Force and the National Cancer Institute, are opposed to routine PSA screening, saying that the risks of follow-up tests and the side effects of treatment may outweigh the possible benefits for many men.
This is a good thing. The mainstream press rarely discusses the fact that PSA testing is so complicated.
I'm on the lookout for good PSA testing patient handouts. Haven't found much. The American Cancer Society's website recently featured this article on calls for informed consent prior to PSA testing.
But until physicians have good tools (educational materials) that will help them provide patients with adequate and reliable information, I'm not sure we'll be improving our track records much. While I often try to have this discussion with patients, I find that it's a tough one to present in an unbiased manner. Men who expect to have test done "because I get one every year .. cuz I'm supposed to" don't want to hear much about the complexity of this decision … and men who don't want to bother with any tests … don't want to bother with any tests .. so they don't get very engaged in the discussion either.
If you use .. or have seen good PSA education materials, please post a comment and share with the rest of us!
http://www.aafp.org/PreBuilt/prostate_patient_tool.pdf
I encourage you to familiarize yourself with all the information you can about screening. I also want you to consider that the Prevention Task Force is a political body. They make policy regarding protocol but their interest is biased in favor of evidence based academic medicine and health cost containment. Therefore, what they say may have esoteric statistical validity but it does not always translate into sound clinical practice. Yet another problem with the task Force is they had no social workers, psychiatrists, or clinical psychologists on the panel but they concluded that men would be too prone to anxiety if PSA testing were mandated. I do not how they could find the chutzpa to say this out loud to American men. It sounds condescending and dismissive.
I am biased—my doctor missed detecting my prostate cancer and now I am D2. I had a biopsy and slightly raised PSA in 1999 but was told “not to worry about it” and I never got to see the letter that said I should be tested every 6 months and that if the PSA went up I should get tested again. When I asked the new MD about PSA I was ignored. This took place in a teaching hospital with a chief of service in one of the top 20 medical schools in the USA. We can only imagine what is happening in some Podunk town if this happpened here. I think he did not read my chart—and I suspect that could happen to anyone—but I think the task force has set the stage for this sort of accident to happen by making screening sort of sound unimportant and confusing.
First off I think you need to rely on your clinical acumen and good patient history to tell if testing is indicated. If I were you I would make sure you have good rapport with the man and then proceed with testing discussion. But before you do this you have to come to grips with the question of what you would do for your self in the same situation. If you are like a lot of evidence based folks you probably think the test is stupid—if you do don’t let this get in the way of how you present it to the patient. You might think about including the patient’s wife or friend in this discussion because the patient will need to talk it over after he leaves your office. Schedule a return visit after he thinks about it and then test him and take him step by step through the decision tree.
I do not think any patient handout is going to really help the guy sort this out—-it sort of sets the stage for having a real human conversation with the doctor he trusts to take care of him. In this age of 10 minute visits and HMO nonsense I don’t know how you guys can do it—-but the therapeutic relationship is critical when you are talking about cancer and terminal illness.
Good luck—I admire you for worrying about this issue.