Research article
Decision Making in Prostate-Specific Antigen Screening: National Health Interview Survey, 2000

https://doi.org/10.1016/j.amepre.2005.12.006Get rights and content

Background

The net benefits and harms of prostate cancer screening with the prostate-specific antigen (PSA) test are uncertain, and professional organizations recommend that physicians discuss these uncertainties with patients before initiating screening. Using a nationally representative sample of men reporting past PSA screening, we aimed to determine the extent to which screening was initiated by physicians and preceded by physician–patient discussions.

Methods

Cross-sectional analysis of data from the 2000 National Health Interview Survey; 2676 men aged 40 and older underwent PSA screening and met study inclusion criteria. We analyzed the proportions of men for whom PSA screening was (1) was initiated by the physician versus the patient, and (2) preceded by discussions about the test’s advantages and disadvantages.

Results

Overall, 74% (95% CI=71.8–76.0) of recipients reported that PSA screening was initiated by their physician, and the proportion increased with advancing age, declining health status, lack of family history of prostate cancer, presence of a usual source of medical care, and non-Hispanic ethnicity. Sixty-five percent (95% CI=63.1–67.1) of screening recipients reported prescreening discussions with their physicians. Discussions were more common with physician-initiated screening than with patient-initiated screening, and among patients reporting a usual source of medical care, non–blue-collar occupation, and black race.

Conclusions

Among U.S. men receiving PSA screening, screening is usually initiated by physicians, frequently in men relatively less likely to benefit from it, and often without prior discussion of the test’s advantages and disadvantages. Further examination of the PSA decision-making process among screened and unscreened men is warranted.

Introduction

Prostate cancer is a common malignancy and a major cause of mortality in men in the United States. It accounts for one third of all diagnosed cancers in U.S. men, and represents the second most common cause of male cancer deaths, and the tenth leading cause of reduced life expectancy.1 In 2005, approximately 232,000 new cases of prostate cancer will be diagnosed in the United States, and approximately 30,000 deaths from prostate cancer will occur.1 The prevalence and mortality burden of prostate cancer have driven widespread screening with the prostate-specific antigen (PSA) test.2

At the same time, however, PSA screening has remained controversial for several reasons. The PSA test itself has limited accuracy and predictive power,3, 4, 5 and leads to frequent false-positive and false-negative results. Prostate cancer also has a heterogeneous, often indolent, natural history, raising questions about the value of early diagnosis by any means.6 The substantial gap between the estimated lifetime risk of developing occult prostate cancer in U.S. men (40% or higher) and the estimated lifetime mortality risk (approximately 3%)7 indicates that most cancers are slow-growing and nonfatal. Thus, prostate cancer screening might cause substantial overdiagnosis,4, 8 rather than real improvements in mortality or morbidity. Finally, the balance of benefits and harms of treating screening-detected prostate cancers is uncertain. Treatments such as radical prostatectomy may reduce prostate cancer mortality in men with early-stage disease9; however, the mortality benefit takes several years to be realized, at the cost of immediate iatrogenic harms that are difficult to estimate precisely, e.g., erectile dysfunction in 20% to 70% of patients and urinary incontinence in 2% to 45%.10

Until ongoing clinical trials are completed,11, 12, 13, 14 these questions about the value of PSA screening remain unresolved.10, 15, 16, 17, 18, 19, 20, 21 Consequently, professional organizations, including the U.S. Preventive Services Task Force,10, 15 American Cancer Society,22 American College of Physicians–American Society of Internal Medicine,23 and the American Urological Association24 have issued PSA screening guidelines that reflect these uncertainties and vary somewhat in their specific recommendations. However, all of these guidelines advocate some form of individualized, rather than universal, PSA screening, and advise clinicians to inform and involve patients in decisions about screening. Several authors have argued that PSA screening should be undertaken only through processes of informed and shared decision making.25, 26, 27

The actual practice of PSA screening, however, does not appear to conform to these recommendations. Several studies have demonstrated significant gaps in men’s knowledge of PSA screening.28, 29, 30, 31 Other studies have shown that recipients of PSA screening are often unaware that they have had it—suggesting that the screening decision was made unilaterally by the physician.32, 33, 34, 35, 36 Furthermore, even when recipients of PSA screening are involved in the decision-making process, they do not always receive sufficient information to participate meaningfully.32, 34, 37

These findings are concerning, and highlight the need for further research to better understand the decision-making process in PSA screening. Past studies have had limited generalizability because of small sample sizes, homogeneous patient populations, and relatively low response rates. Furthermore, previous research has not fully explored the factors influencing PSA screening decisions. For example, the influence of patient sociodemographic characteristics on screening decisions has only begun to be examined. It is also unclear who is driving the demand for PSA screening—physicians or patients—although this factor might influence not only decisions to screen, but the extent to which decisions are informed and shared.38, 39, 40, 41, 42, 43, 44, 45, 46

In the current study, data from the 2000 National Health Interview Survey (NHIS) were used to examine the decision-making process regarding PSA screening. Focusing on PSA screening recipients in the U.S. population, analyses were performed to assess the extent to which screening was (1) initiated by physician versus patient, and (2) preceded by discussions about the advantages and disadvantages of the test. Patient characteristics associated with these outcomes were also explored, with the objective of determining the extent to which physician-initiated PSA screening involved appropriate candidates for screening and influenced the occurrence of prescreening physician–patient discussions.

Section snippets

Data Source

The NHIS, an annual health survey conducted by the National Center for Health Statistics, is one of the principal sources of health information on the civilian, non-institutionalized population in the United States.47 Each annual survey collects information on respondents’ health, demographic and socioeconomic characteristics, and access to and use of health services. The surveys also contain annual supplements addressing particular health issues. In 2000, the NHIS was supplemented by the

Results

The characteristics of men aged 40 or older who underwent PSA screening (Table 1) reflect the patterns of PSA use previously described in the NHIS sample population.2 The majority of PSA screening recipients were aged 50 to 69, non-Hispanic white, and reported relatively high levels of education, income, access to health care, and general health.

Discussion

This study raises several important issues about decision making regarding PSA screening in U.S. men. The substantial proportion of PSA recipients whose screening was initiated by physicians corroborates past evidence of widespread physician support for routine PSA screening56, 57, 73, 74, 75, 76, 77 and suggests that this screening is being driven primarily by physicians. In addition, the study provides evidence that physicians may not be appropriately individualizing PSA screening.

In this

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