Patient Perceptions and Shared Decisions About PSA Screening

Prostate Cancer

Prostate Cancer continued surgical and medical management of benign prostatic hyperplasia and its effects on PSA levels. Three PSA assays were used throughout the study period which may result in pseudoacceleration or pseudodeceleration.14 Furthermore, the study registry did not capture prostate cancer diagnoses that occurred after membership termination. Finally, concern has been expressed about inconsistency between the data presented in the figures and text, which requires additional clarification.15 Discussion Contrary to what has been previously suggested,15 no randomized trial has evaluated the outcomes of a screening program based on PSA kinetics. Each of the many observational studies and secondary analyses of PSAV has important drawbacks. However, the absence of evidence is not evidence of absence.16 If confirmed, the studies of Ørsted and colleagues6 and Wallner and associates7 will add to the growing body of literature supporting the value for PSA kinetics in improving detection beyond that of a single baseline PSA measurement. In particular, these studies suggest that PSAV may be useful when screening for aggressive disease, with the goal of ultimately reducing unnecessary prostate biopsies and overdiagnosis. Additional prospective evaluation is necessary to confirm that PSAV may identify men at a time point when their disease is curable and may benefit from curative intervention. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Eggener SE, Yossepowitch O, Roehl KA, et al. Relationship of prostate-specific antigen velocity to histologic findings in a prostate cancer screening program. Urology. 2008;71:1016-1019. Loeb S, Roehl KA, Helfand BT, et al. Can prostate specific antigen velocity thresholds decrease insignificant prostate cancer detection? J Urol. 2010;183:112-116. Loeb S, Metter EJ, Kan D, et al. Prostate-specific antigen velocity (PSAV) risk count improves the specificity of screening for clinically significant prostate cancer. BJU Int. 2012;109:508-513; discussion 513-514. Vickers AJ, Wolters T, Savage CJ, et al. Prostate-specific antigen velocity for early detection of prostate cancer: result from a large, representative, population-based cohort. Eur Urol. 2009;56:753-760. Vickers AJ, Till C, Tangen CM, et al. An empirical evaluation of guidelines on prostate-specific antigen velocity in prostate cancer detection. J Natl Cancer Inst. 2011;103: 462-469. Ørsted DD, Bojesen SE, Kamstrup PR, Nordestgaard BG. Long-term prostate-specific antigen velocity in improved classification of prostate cancer risk and mortality. Eur Urol. 2013;64:384-393. Wallner LP, Frencher SK, Hsu JW, et al. Changes in serum prostate-specific antigen levels and the identification of prostate cancer in a large managed care population. BJU Int. 2013;111:1245-1252. Pencina MJ, D’Agostino RB Sr, D’Agostino RB Jr, Vasan RS. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008;27:157-172; discussion 207-212. Vickers AJ, Pencina M. Prostate-specific antigen velocity: new methods, same results, still no evidence of clinical utility. Eur Urol. 2013;64:394-396. Ulmert D, Serio AM, O’Brien MF, et al. Long-term prediction of prostate cancer: prostatespecific antigen (PSA) velocity is predictive but does not improve the predictive accuracy of a single PSA measurement 15 years or more before cancer diagnosis in a large, representative, unscreened population. J Clin Oncol. 2008;26:835-841. Wolters T, Roobol MJ, Bangma CH, Schroder FH. Is prostate-specific antigen velocity selective for clinically significant prostate cancer in screening? European Randomized Study of Screening for Prostate Cancer (Rotterdam). Eur Urol. 2009;55:385-392. 12. 13. 14. 15. 16. Carter HB, Ferrucci L, Kettermann A, et al. Detection of life-threatening prostate cancer with prostate-specific antigen velocity during a window of curability. J Natl Cancer Inst. 2006;98:1521-1527. Loeb S, Metter EJ, Kan D, et al. Prostate-specific antigen velocity (PSAV) risk count improves the specificity of screening for clinically significant prostate cancer. BJU In. 2012;109:508-513; discussion 513-514. Loeb S, Chan DW, Sokoll L, et al. Prostate specific antigen assay standardization bias could affect clinical decision making. J Urol. 2008;180:1959-1962; discussion 1962-1963. Vickers AJ. Prostate cancer: Why is PSA velocity such a sticky concept? Nat Rev Urol. 2013;10:189-190. Perrin P. PSA velocity and prostate cancer detection: the absence of evidence is not the evidence of absence. Eur Urol. 2006;49:418-419. Patient Perceptions and Shared Decisions About PSA Screening Reviewed by Daniel Wollin, MD, Stacy Loeb, MD Department of Urology, New York University and the Manhattan Veterans Affairs Hospital, New York, NY [Rev Urol. 2013;15(4):206-207 doi:10.3909/riu0600] © 2014 MedReviews®, LLC T he past few years have witnessed a rapidly changing panorama regarding recommendations for prostate cancer screening. At one extreme, the United States Preventive Services Task Force (USPSTF) issued a grade D recommendation against prostate-specific antigen (PSA) screening.1 Meanwhile, most other groups recommend shared decision making about screening, including a discussion between patients and physicians about the associated controversies and taking into consideration patient preferences.2 For example, the American Urological Association (AUA) recently issued new guidelines supporting shared decision making about PSA testing for average-risk men aged 55 to 69 years, while opposing PSA testing as part of health fairs and other community settings in which shared decision making is not part of routine practice.3 Two recent studies have attempted to quantify the effect of these changing recommendations on patient perceptions and patient-physician discussions regarding PSA screening. National Evidence on the Use of Shared Decision Making in ProstateSpecific Antigen Screening Han PK, Kobrin S, Breen N, et al. Ann Fam Med. 2013;11:306-314. Proper shared decision making between a patient and physician involves several components, including a discussion of the advantages, disadvantages, and scientific uncertainties. The goal of this study was to assess the extent to which shared decision making is actually used for PSA screening decisions and its implications. 206 • Vol. 15 No. 4 • 2013 • Reviews in Urology 4004170006_RIULitra.indd 206 16/01/14 5:12 PM Prostate Cancer Of 4217 men aged 50 to 74 years from the nationally representative sample of the 2010 National Health Interview Survey, 3427 men responded to a questionnaire about the nature of the prescreening conversation with their physician. Whether the physician was an internist, urologist, or other health professional was not addressed. In total, 55.8% of men reported at least one previous PSA test, whereas 44.2% of the study population reported never being screened. Overall, only 8.0% of the participants described conversations that included all three required components of shared decision making (advantages, disadvantages, and uncertainties). Conversely, 64.3% reported no discussion whatsoever. Higher screening intensity (4 to 5 PSA tests/5 years) was associated with partial shared decision making (1 or 2 of the required elements), along with increased age, higher education, and physician recommendation. Importantly, the vast majority of nonscreened men— 88% (95% confidence interval, 86.2-90.1)—reported no discussion of PSA screening whatsoever. That is, the authors observed a significantly greater degree of uninformed nonuptake compared with uninformed uptake. There are several limitations to this study, most significantly the reliance on self-reporting of screeningrelated conversations, which can be inaccurate.4 For example, patients who underreport PSA screening may also underreport shared decision making, potentially inflating the degree of uninformed nonuptake. However, a lack of screening in the absence of discussion is a feasible and troubling possibility, particularly given that primary care physicians may no longer feel obliged to discuss PSA with patients given the USPSTF grade D recommendation. Overall, this study revealed the pervasiveness of incomplete dialogues regarding the risks, benefits, and uncertainties of PSA screening in contemporary patient-physician encounters. Prostate-specific Antigen Testing: Men’s Responses to 2012 Recommendation Against Screening Squiers LB, Bann CM, Dolina SE, et al. Am J Prev Med. 2013;45:182-189. This study attempted to evaluate the awareness and attitudes of men in the United States toward the October 2011 USPSTF draft recommendation against PSA screening (which was officially announced in May 2012). One month after the draft was released (November–December 2011), online surveys were distributed to 1800 men aged 40 to 74 years asking about their degree of agreement with the new recommendation. Overall, 67.7% responded, of which 1089 had no history of prostate cancer and were thus eligible for participation. In this sample, 44% of patients had a PSA test within the past 2 years, and 39% reported never receiving a PSA test. Most men (70%) reported no discussion or did not recall a discussion about the benefits and harms of PSA screening with their provider. At the time of the survey, . 75% of participants had not heard about the new draft recommendation. Once shown the new recommendation, participants were asked if they would follow it and avoid PSA screening in the future. Overall, only 13% stated they would avoid further screening, whereas 54% planned to ignore the recommendation, and 33% had not decided. Logistic regression identified the following features as those significantly associated with intending to not follow the recommendation: black race/ethnicity, higher income, worried about developing prostate cancer, and having had a PSA checked within 2 years. The greatest limitation of this study is its timing— the survey was conducted less than 1 month after the distribution of a draft recommendation and a majority of the participants had little to no exposure to the source material prior to the study. Given the significant amount of media coverage and policy discussion since this draft and several subsequent guidelines, the average male patient may now have greater exposure to the controversy. In summary, it is important to note that both these studies were performed prior to the official release of the updated USPSTF and AUA guidelines (2012 and 2013, respectively). Nevertheless, they highlight the fact that many contemporary patients were not well educated by their physicians regarding the potential benefits, harms, and uncertainties of PSA screening. Given that most organizations now recommend shared decision making, a unilateral decision by physicians to blindly screen or not to discuss screening as an option is concerning. Although time consuming, it is important that patients are given full information about the risks, benefits, and uncertainties of screening to actively participate in an informed decision-making process. References 1. 2. 3. 4. Moyer VA, for the USPSTF. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120-134. Basch E, Oliver TK, Vickers A, et al. Screening for prostate cancer with prostate-specific antigen testing: American Society of Clinical Oncology Provisional Clinical Opinion. J Clin Oncol. 2012;30:3020-3025. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA Guideline. J Urol. 2013;190:419-426. Rauscher GH, Johnson TP, Choi YI, Walk JA. Accuracy of self-reported cancer-screening histories: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 2008;17:748-757. Vol. 15 No. 4 • 2013 • Reviews in Urology • 207 4004170006_RIULitra.indd 207 16/01/14 5:12 PM