Recent Patterns in Shared Decision Making for Prostate-Specific Antigen Testing in the United States

Stacey A. Fedewa; Ted Gansler; Robert Smith; Ann Goding Sauer; Richard Wender; Otis W. Brawley; Ahmedin Jemal

doi:10.1370/afm.2200

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SDM for prostate cancer screening: how can we get it right?
Kevin J. Selby

Published on: 21 March 2018

Published on: (21 March 2018)
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SDM for prostate cancer screening: how can we get it right?
Kevin J. Selby, Chef de Clinique
I, like many of my primary care colleagues, breathed a sigh of relief when the USPSTF released their D recommendation for prostate cancer screening with PSA in 2012. Finally I could stop wasting time having stilted, awkward conversations with my male patients informing them about prostate cancer. Proactive conversations informing my patients that it is possible to be screened, but then usually guiding them towards the co...
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I, like many of my primary care colleagues, breathed a sigh of relief when the USPSTF released their D recommendation for prostate cancer screening with PSA in 2012. Finally I could stop wasting time having stilted, awkward conversations with my male patients informing them about prostate cancer. Proactive conversations informing my patients that it is possible to be screened, but then usually guiding them towards the conclusion that the risks of screening outweigh the benefits for most men.
Several reports from the literature now show that primary care providers are ordering less PSA tests than previously. This report from Fedewa et al shows that we are not engaging in substantially more discussions with men about the benefits and risks of screening. It seems that the generation of doctors before me ordered PSAs without discussing the repercussions with their patients; my generation stopped ordering the test altogether, but still doesn't discuss PSA testing with most patients.
Reading through the new draft USPSTF recommendations in more detali, I have come to believe that they've actually gotten it right this time. There is evidence of a small decrease in prostate cancer-related mortality with PSA testing, and it is the only viable method for early detection of a common, deadly cancer. Some informed men may want screening, though it is likely to be a minority and it definitely shouldn't be the default choice.
But what isn't at all clear to me is how to operationalize this recommendation. When I bring up a test or treatment to my patients, they are accustomed to an opt-out approach. They have high blood pressure, I discuss treatment, and unless they object, they end up with a prescription. I am genuinely not sure how to efficiently discuss prostate cancer screening with the majority of my male patients aged 55 to 69 in order to identify the minority of men who will want screening despite the significant risks involved. New approaches are needed.
Competing interests: None declared
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Competing Interests: None declared.