Patient Education for Informed Decision Making About Prostate Cancer Screening: A Randomized Controlled Trial with 1-Year Follow-Up

Robert J. Volk; Stephen J. Spann; Alvah R. Cass; Sarah T. Hawley

doi:10.1370/afm.7

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Ethics of Informed Consent in Preventive Care and the Limits of Patient Education
M Jawad Hashim

Published on: 13 June 2003

Published on: (13 June 2003)
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Ethics of Informed Consent in Preventive Care and the Limits of Patient Education
M Jawad Hashim, Attending Family Physician
Dear Editor,
Volk and colleagues(1) report a reduction in PSA testing with only 34% of men opting for screening after watching a decision-aid video tape compared to 55% in the control group. Although a well conducted controlled trial, I am concerned about the practical difficulties in applying its findings to non-research settings.
The process of informed consent involves communication, patient compreh...
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Dear Editor,
Volk and colleagues(1) report a reduction in PSA testing with only 34% of men opting for screening after watching a decision-aid video tape compared to 55% in the control group. Although a well conducted controlled trial, I am concerned about the practical difficulties in applying its findings to non-research settings.
The process of informed consent involves communication, patient comprehension and decision-making. The ethics of preventive care involves informed consent but poses significant burden on physicians to inform and educate themselves and their patients.(2) Unfortunately, knowledge of prostate cancer screening with PSA is fairly limited in the target population.(3) In addition, primary care physicians and urologists differ in their emphasis on the uncertainties in prostate cancer screening.(4) Finally, the combined recommendations for screening add up to a considerable number of issues to be addressed with the patient.(5)
I believe we are at the limits of informed patient decision-making in preventive medicine. In complex issues with uncertainties and experts with stakes, it may not be always possible to educate patients fully. Patients’ ability to assimilate evidence data and even evaluate future risks preferences may be limited and time variable. Alternative models of decision-making in preventive care may be worth be exploring, including prioritizing by cost-effectiveness and physician reimbursement that is neutral to decision-making. The latter is probably more feasible at the primary care level.
At present, malpractice concerns and local ‘standards of care’ seem to influence decision-making more than evidence-based medicine.(6)
Sincerely,
M Jawad Hashim MBBS
Port Orchard Washington
1. Volk RJ, Spann SJ, Cass AR, Hawley ST. Patient Education for Informed Decision Making About Prostate Cancer Screening: A Randomized Controlled Trial with 1-Year Follow-Up. Ann Fam Med 2003;1(1):22-28.
2. Marshall KG. Prevention. How much harm? How much benefit? 4. The ethics of informed consent for preventive screening programs. Cmaj 1996;155(4):377-83.
3. Chan EC, Vernon SW, O'Donnell FT, Ahn C, Greisinger A, Aga DW. Informed consent for cancer screening with prostate-specific antigen: how well are men getting the message? Am J Public Health 2003;93(5):779-85.
4. Chan EC, Vernon SW, Haynes MC, O'Donnell FT, Ahn C. Physician Perspectives on the Importance of Facts Men Ought to Know About Prostate- specific Antigen Testing. J Gen Intern Med 2003;18(5):350-356.
5. Medder JD, Kahn NB, Jr., Susman JL. Risk factors and recommendations for 230 adult primary care patients, based on U.S. Preventive Services Task Force guidelines. Am J Prev Med 1992;8(3):150-3.
6. Collins MM, Fowler FJ, Jr., Roberts RG, Oesterling JE, Annas GJ, Barry MJ. Medical malpractice implications of PSA testing for early detection of prostate cancer. J Law Med Ethics 1997;25(4):234-42, 230.
Competing interests: None declared
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Competing Interests: None declared.