Primary Care Physicians’ Use of an Informed Decision-Making Process for Prostate Cancer Screening

The well-designed study by Volk and colleagues reported that 24% of the primary care physician respondents failed to discuss screening before ordering a PSA test. These findings are disconcerting because the survey was conducted in 2007, when contemporaneous guidelines were consistently encouraging informed decision-making. The respondents who screened without discussion were significantly more likely than those who discussed screening to cite time constraints and malpractice concerns. These are important issues, and the authors appropriately suggest that providing patients with decision aids could effectively overcome these barriers. Decision aids can provide information about prostate cancer and screening tests, the potential benefits and harms of screening, the probabilities for these outcomes, and help patients clarify and communicate their values. These decision support tools, which can be written, video, or web-based, have been shown to increase knowledge and reduce decisional conflict (1), as well as potentially facilitating shorter, more focused clinic discussions.

Furthermore, Washington State has passed legislation recognizing that using a decision aid constitutes evidence of an informed consent. Volk and colleagues note that a lawyer, commenting on this legislation, has argued that using decision aids "establishes a higher burden of proof for patients attempting to claim that they were not adequately informed of risks or alternatives (2)." Barry and colleagues tested this hypothesis by conducting a mock trial based on the Merenstein case (3). Dr. Merenstein was a family medicine resident when he discussed prostate cancer screening with a new patient who elected not to be tested (4). When advanced cancer was subsequently detected following a PSA test ordered by another doctor—who did not discuss testing—Dr. Merenstein and his training program were successfully sued for failing to practice standard of care (though Dr. Merenstein himself was exonerated). In the mock trial, even when jurors were told that the discussion was documented in the medical record (as Dr. Merenstein did), the majority concluded that the physician had not met the standard of care and had harmed the patient. However, when the jurors were told that the patient decided against screening after viewing a decision aid (which was shown to the jurors), almost all concluded that the physician had met the standard of care.

Screening for prostate cancer is a complex, controversial, and important health decision that should be based on the preferences of an informed patient. Health care providers should engage patients in the decision-making process—and this can be facilitated by using a decision aid.

1. Volk RJ, Hawley ST, Kneuper S, et al. Trials of decision aids for prostate cancer screening: a systematic review. Am J Prev Med 2007;33(5): 428-34.
2. Moulton B, King JS. Aligning ethics with medical decision-making: the quest for informed patient choice. J Law Med Ethics 2010;38(1): 85-97.
3. Barry MJ, Wescott PH, Reifler EJ, Chang Y, Moulton BW. Reactions of potential jurors to a hypothetical malpractice suit: alleging failure to perform a prostate-specific antigen test. J Law Med Ethics 2008;36(2): 396-402, 214.
4. Merenstein D. A piece of my mind. Winners and losers. JAMA 2004;291(1): 15-6.

Competing interests:   I edit the prostate cancer screening decision aid produced by the Informed Medical Decisions Foundation