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Research ArticleOriginal Research

National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening

Paul K. J. Han, Sarah Kobrin, Nancy Breen, Djenaba A. Joseph, Jun Li, Dominick L. Frosch and Carrie N. Klabunde
The Annals of Family Medicine July 2013, 11 (4) 306-314; DOI: https://doi.org/10.1370/afm.1539
Paul K. J. Han
1Maine Medical Center Research Institute, Portland, ME; Tufts University School of Medicine, Boston, Massachusetts
MD, MA, MPH
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  • For correspondence: hanp@mmc.org
Sarah Kobrin
2Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
PhD
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Nancy Breen
3Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
PhD
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Djenaba A. Joseph
4Centers for Disease Control and Prevention, Atlanta, Georgia
MD, MPH
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Jun Li
4Centers for Disease Control and Prevention, Atlanta, Georgia
MD, PhD
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Dominick L. Frosch
5Palo Alto Medical Foundation Research Institute, Palo Alto, California
6Department of Medicine, University of California, Los Angeles, California
PhD
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Carrie N. Klabunde
3Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
PhD
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Article Figures & Data

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  • Figure 1
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    Figure 1

    Study population of men aged 50–74 years, National Health Interview Survey, 2010.

  • Figure 2
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    Figure 2

    Extent of shared decision making by intensity level of PSA screening, 2010 National Health Interview Survey

    PSA=prostate-specific antigen.

    Notes: Extent of shared decision making (unadjusted percentages) according to the physician’s discussion of the following elements: advantages, disadvantages, and uncertainty. Fully informed is discussion of all elements. Partially informed/shared (pros+cons/uncertainty) is discussion of advantages and disadvantages or advantages and uncertainty. Partially informed/shared (pros-only) is discussion of advantages only. Partially informed/shared (cons-only) is discussion of disadvantages only, disadvantages and uncertainty, or uncertainty only. Fully uninformed/unshared is no discussion of decision-making elements. PSA screening intensity levels are as follows: no screening = no past history; low-intensity = 1–3 tests in past 5 years; high-intensity = 4–5 tests in past 5 years.

Tables

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    Table 1

    Characteristics of Study Population (N = 3,427), 2010 National Health Interview Survey

    Characteristic, No. RespondingPercenta
    Age, years, N=3,427
     50–5954.0
     60–6936.1
     70–749.9
    Race, N=3,427
     White85.0
     Black9.9
     Other5.1
    Ethnicity, N=3,427
     Hispanic9.8
     Non-Hispanic90.2
    Education, n=3,415
     <High school graduate15.0
     High school graduate26.2
     Some college/technical school25.5
     College grad33.3
    Poverty ratio, N=3,427
     <200%20.7
     200%–299%11.9
     300%–399%10.2
     400%–499%10.1
     ≥500%30.0
     Unknown17.1
    Health insurance, n=3,422
     None11.3
     Public only16.7
     Private/military71.9
    Usual source of medical care, n=3,425
     Yes88.1
     No11.9
    Reported health status, N=3,427
     Excellent22.8
     Very good29.8
     Good29.5
     Fair or poor17.9
    Family history of prostate cancer, N=3,427
     Yes6.8
     No/unknown93.2
    Chronic diseases, n=3,412
     None39.4
     133.4
     218.2
     ≥39.0
    Cancer, n=3,421b
     Yes5.9
     No94.1
    Doctor recommended PSA screening, n=3,417
     Yes52.5
     No47.5
    Ever had a PSA test, N=3,427
     Yes55.8
     No44.2
    Date of last PSA test, n=1,826
     ≤1 Year ago65.5
     >1 But less than 5 years ago29.0
     >5 Years ago5.6
    Screening intensity (PSA tests in 5 y), n = 3,355
     None47.1
     1–3 (low intensity)27.8
     4–5 (high intensity25.1
    • PSA=prostate-specific antigen.

    • Note: Respondents were men aged 40 to 75 years with no prior PSA testing or who had PSA testing as part of routine examination; not all categories sum to 3,427 because of missing data.

    • ↵a Percentages weighted to the US civilian noninstitutionalized population.

    • ↵b Excluding prostate and nonmelanoma skin cancer.

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    Table 2

    Prevalence of Elements of Shared Decision Making in PSA Screening Study Population (N=3,427), 2010 National Health Interview Survey

    Element, No. RespondingPercenta
    Discussion of advantages/disadvantages, n = 3,344
     None65.1
     Advantages only16.9
     Disadvantages only0.9
     Both17.0
    Discussion of uncertainty, n = 3,344
     Yes12.1
     No87.9
    Extent of shared decision making,b n=3,304
     No elements64.3
     Partial, disadvantages only, disadvantages and uncertainty, or uncertainty only2.5
     Partial, advantages only14.6
     Partial, advantages and disadvantages or advantages and uncertainty10.7
     All elements8.0
    • PSA=prostate-specific antigen.

    • Note: Respondents were men aged 40–75 years with no prior PSA testing or who had PSA testing as part of routine examination (N = 3,427); not all categories sum to 3,427 because of missing data.

    • ↵a Percentages weighted to the US civilian noninstitutionalized population.

    • ↵b Physician discussion of the following elements: advantages, disadvantages, and uncertainty.

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    Table 3

    Factors Associated with PSA Screening Intensity,a 2010 National Health Interview Survey

    FactorLow Intensity vs No Screeninga
    OR (95% CI)b
    High Intensity vs No Screening
    OR (95% CI)b
    P Valuec
    Age, year<.001
     50–591.01.0
     60–691.41 (1.07–1.86)2.95 (2.12–4.11)
     70–741.54 (0.90–2.65)4.59 (2.68–7.87)
    Education.002
     <High school graduate1.01.0
     High school graduate1.37 (0.90–2.08)1.56 (0.84–2.89)
     Some college/technical institute1.00 (0.64–1.56)1.68 (0.95–2.96)
     College graduate1.58 (0.97–2.57)2.92 (1.55–5.49)
    Usual source of medical care<.001
     Yes1.01.0
     No0.46 (0.29–0.74)0.15 (0.06–0.38)
    Doctor recommendation<.001
     Yes44.10 (31.68–61.41)107.37 (71.42–161.41)
     No1.01.0
    Extent of shared decision makingd<.001
     No elements1.01.0
     Partial, disadvantages only, disadvantages and uncertainty, or uncertainty only3.84 (1.24–11.91)4.87 (1.48–16.02)
     Partial, advantages only2.38 (1.53–3.71)3.22 (1.94–5.35)
     Partial, advantages and disadvantages or advantages and uncertainty3.97 (1.82–8.68)3.82 (1.67–8.69)
     All elements1.98 (0.97–4.04)1.96 (0.93–4.11)
    • ↵a PSA Screening intensity: “no screening” = no prior testing; “low intensity” = 1–3 tests/past 5 years; “high intensity” = 4–5 tests/past 5 years

    • ↵b Confidence interval from multivariable polytomous logistic regression model with PSA screening as the dependent variable (n = 3,209); analyses adjusted for race, ethnicity, poverty ratio, self-reported health status, number of chronic diseases, personal history of cancer, family history of prostate cancer, health insurance.

    • ↵c P value for Wald χ2 test for association.

    • ↵d Physician discussion of the following elements: advantages, disadvantages, and uncertainty.

    • View popup
    Table 4

    Factors Associated with Physician-Patient Discussion of Advantages and Disadvantages of PSA Screening and Uncertainty About PSA Screening, 2010 National Health Interview Survey

    Discussion of Advantages and DisadvantagesaDiscussion of Uncertaintyb
    FactorAdvantages or Disadvantages vs No Discussion
    OR (95% CI)
    Advantages and Disadvantages vs No Discussion
    OR (95% CI)
    P ValuecUncertainty vs No Discussion
    OR (95% CI)
    P Valuec
    Race<.001
     White1.01.0–
     Black1.09 (0.76–1.56)2.47 (1.73–3.53)–
     Other0.99 (0.60–1.64)1.34 (0.79–2.28)–
    Ethnicity.005–
     Hispanic1.16 (0.75–1.79)2.03 (1.32–3.13)–
     Non-Hispanic1.01.0–
    Education<.001
     <High school graduate–––1.0
     High school graduate–––1.44 (0.81–2.57)
     Some college/technical school–––1.27 (0.70–2.30)
     College graduate–––2.61 (1.49–4.58)
    Health insurance.002
     None–––0.24 (0.10–0.58)
     Public only–––0.66 (0.44–0.99)
     Private/military–––1.0
    Doctor recommendation<.001
     Yes9.24 (6.63–12.88)10.56 (7.47–14.92)–
     No1.01.0–
    Discussion of uncertainty<.001
     Yes5.42 (3.28–8.98)38.79 (23.57–63.83)–
     No1.01.0–
    Discussion of advantages/disadvantages<.001
     None–––1.0
     Advantages or disadvantages–––5.30 (3.26–8.60)
     Both–––38.23 (23.49–62.22)
    • OR=odds ratio.

    • ↵a Multivariable polytomous logistic regression model with discussion of advantages and disadvantages of PSA screening as the dependent variable (n = 3,260); analyses adjusted for age, education, poverty ratio, self-reported health status, number of chronic diseases, personal history of cancer, family history of prostate cancer, health insurance, usual source of medical care.

    • ↵b Multivariable logistic regression model with discussion of uncertainty about PSA screening as the dependent variable (n = 3,260); analyses adjusted for age, poverty ratio, self-reported health status, number of chronic diseases, personal history of cancer, family history of prostate cancer, usual source of medical care.

    • ↵c Wald χ2 test for association.

Additional Files

  • Figures
  • Tables
  • The Article in Brief

    National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening

    Paul K. J Han , and colleagues

    Background The prostate-specific antigen (PSA) test, which screens for prostate cancer, has limited accuracy, and there is conflicting evidence for its effectiveness in reducing mortality. Because of the nature of prostate cancer, PSA screening can lead to overdiagnosis and unnecessary evaluation and treatment. Professional organizations therefore recommend that clinicians inform patients about the pros, cons, and uncertainties of PSA screening, and that screening decisions be based on patient preferences. This study examines the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.

    What This Study Found Most US men report little shared decision making in PSA screening, and the absence of shared decision making is more prevalent in men who are not screened. Nearly two-thirds of men report no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty of PSA screening (no shared decision making); 28 percent report discussion of 1 to 2 elements (partial shared decision making); and 8 percent report discussion of 3 elements (full shared decision making). Forty-four percent of participants report no PSA screening, 28 percent report less than annual screening, and 25 percent report nearly annual screening. The extent of shared decision making is associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity is associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial shared decision making.

    Implications

    • These findings, the authors assert, justify a broader policy debate about PSA screening. Much of the debate has focused on the absence of shared decision making in PSA screening and the potential harm of undesired and unnecessary treatment. This study suggests the more prevalent problem is the absence of shared decision making in nonscreening--the harm of which is the failure to allow individuals to decide for themselves whether screening is beneficial.
  • Supplemental Table

    Supplemental Table 1. Factors Associated With PSA Screening Intensity (Unadjusted Analyses), 2010 National Health Interview Survey

    Files in this Data Supplement:

    • Supplemental data: Table - PDF file, 1 page, 184 KB
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The Annals of Family Medicine: 11 (4)
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National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening
Paul K. J. Han, Sarah Kobrin, Nancy Breen, Djenaba A. Joseph, Jun Li, Dominick L. Frosch, Carrie N. Klabunde
The Annals of Family Medicine Jul 2013, 11 (4) 306-314; DOI: 10.1370/afm.1539

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National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening
Paul K. J. Han, Sarah Kobrin, Nancy Breen, Djenaba A. Joseph, Jun Li, Dominick L. Frosch, Carrie N. Klabunde
The Annals of Family Medicine Jul 2013, 11 (4) 306-314; DOI: 10.1370/afm.1539
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