Men considering prostate cancer screening should receive a brief, basic message about the possible benefits and harms of the prostate-specific antigen (PSA) blood test, according to a new recommendation from the Massachusetts Prostate Cancer Screening Guideline Panel.
The panel, convened by UMass Medical School family physician and preventive health screening researcher Roger Luckmann, MD, MPH, concludes in its new Clinical Practice Guideline that a shared decision making process is the best approach to assuring that men are fully prepared to make an informed decision about whether to undergo PSA screening. The guideline was released by the Massachusetts Health Quality Partnership (MHQP).
“If a man goes through a well-designed, shared decision making process, there are known benefits, based on good evidence, that he feels less conflicted, understands the decision and is satisfied with it,” said Dr. Luckmann, associate professor of family medicine and community health. “These are soft but well-documented outcomes.”
Widespread PSA testing in the United States has led to many men being diagnosed with and treated for prostate cancer, despite very limited and equivocal evidence that the screening has reduced deaths from prostate cancer. There is strong evidence that a substantial proportion of screened men have experienced significant harm from inconclusive results and overtreatment. The lack of strong clinical evidence for PSA testing effectiveness has led to inconsistent recommendations for and against it from the U.S. Preventive Services Task Force, the American Cancer Society and the American Urological Association.
“Some patients in Massachusetts may be getting the message that prostate cancer screening is not recommended or hear nothing at all about screening, while others are offered PSA testing with or without some discussion of the benefits and harms,” said Luckmann, who has conducted extensive research on the effectiveness of clinical preventive services including screening tests and counseling strategies.
The recommendation that “men who express an interest in learning more about PSA screening after receiving the basic information should be offered an opportunity to engage in a shared decision” is based on patient-oriented evidence deemed consistent and of good quality by the panel. Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction and quality of life.
“The uncertainty about benefit that an individual may receive from screening and the high likelihood of men experiencing significant harm from screening make it imperative that men fully appreciate these issues before making a decision about screening,” the panel wrote. “A systematic shared decision making process is the best approach to assuring that men are fully prepared to make an informed decision.”
The panel’s work was funded by a 2012 grant to Luckmann from the Patient Centered Outcomes Research Institute (PCORI). PCORI is an independent, non-profit organization established by Congress in 2010 with its mission to fund research that will provide patients, caregivers and clinicians with the evidence-based information needed to make better-informed health care decisions.
“The concept of shared decision making has been well-received by the medical community,” said Luckmann. “A provider should both understand the science and the evidence and help interpret that, and at the same time be a sounding board for the man trying to make the decision, reflecting back on where the patient is headed and using their knowledge of the person to offer opinions.”
The 21-member panel comprised patients, primary care providers, urologists, and representatives from payers, health systems and the Massachusetts Department of Public Health to ensure it had input from multiple prostate cancer screening stakeholders. They developed the guideline through an interactive, iterative process facilitated by The Mediation Group of Boston.
Members were identified and selected by the research and facilitation teams established through the PCORI grant and MHQP. Established in 1995, MHQP provides reliable information to help physicians improve the quality of care they provide their patients and help people take an active role in making informed decisions about their health care.
“A well known, credible organization has now published its prostate cancer screening recommendation based on our guideline,” Luckmann concluded.
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