Wheeler et al. BMC Cancer 2011, 11:148 http://www.biomedcentral.com/1471-2407/11/148 screening while the American trial reported no mortality difference. The hope that these studies would provide further clarity and direction for PSA screening did not materialize. A more recently published population-based screening trial reported a cumulative relative risk reduc- tion of death as a result of prostate cancer of 50% in the screening group, however the risk of overdiagnosis was still substantial [4]. In addition to the inconsistent results of the clinical trials, there is disagreement in PSA screen- ing guidelines from major health organizations [5-8]. The fact that PSA testing leads to overdiagnosis and overtreatment of prostate cancer and subsequent harms, such as incontinence and impotence, adds to the contro- versy about PSA screening. Given the ongoing contro- versy, the responsibility for the decision to screen a man for prostate cancer is a key issue in the PSA debate. In this paper, we discuss the challenges of decision making for PSA screening for prostate cancer and argue for aug- menting the existing approaches of informed decision making (IDM) and shared decision making (SDM) with strategies from libertarian paternalism (LP) to improve decision making. Discussion Existing decision-making approaches Traditionally, medical practice has been a paternalistic sys- tem, with the health care provider telling the patient what to do and making the final decisions regarding screening or treatment. More recently, informed decision making and the related concept of shared decision making are increasingly being advocated, and several health organiza- tions recommend that a patient be well informed about the risks and benefits of screening with PSA, and that he dis- cusses his screening decision with his health care provider [5]. Both approaches of IDM and SDM aim to empower patients to choose among the available options by making them active participants in the decision making process [9,10]. In the IDM approach, the patient is presented with all the information pertinent to making a decision and then assumes final authority for the decision. In the SDM approach, the patient is provided with all the relevant information and works with the health care provider to reach a decision that reflects the health preference of the patient [11]. Traditionally, the information relevant to the clinical decision has been conveyed verbally to the patient by the health care provider. An increasingly important part of the IDM and SDM approaches is decision aids, which are designed to consis- tently deliver comprehensive and objective information to the patient. Decision aids, such as an informational video- tape or pamphlet, have been shown to increase patient knowledge about prostate cancer and its management options [12-15]. Information relevant to the clinical deci- sion conveyed verbally to the patient by the health care Page 2 of 7 provider can be supplemented with the use of a decision aid [16]. Several studies have shown that a significantly lower proportion of patients choose PSA testing among those who were given decision aids to assist in informed consent [17,18] and SDM [13,19] compared to those in control groups. The American Cancer Society, a long-time advocate of IDM, recommends in its most recent guide- lines the use of decision aids [8]. Decision aids also have a potentially important role in malpractice defence by enabling practitioners to document that the screening decision of a patient was an informed one based on reviewing a decision aid [20,21]. Proponents of the IDM and SDM approaches argue that one of the important benefits of these approaches is that the final decision for screening or treatment is more in agreement with the values and best interests of the patient than in the traditional paternalist approach [8,22]. While this is certainly true, by increasing involvement of patients in the clinical decision-making process, IDM/ SDM places more of the responsibility and pressure for a complex decision on the patient. Challenges to decision-making In practice, several challenges to decision making for PSA screening remain. Various prostate cancer screening guidelines recommend a balanced discussion between the health care provider and the patient about risks and benefits of PSA screening prior to screening [7,8]. How- ever, research suggests that these discussions are not consistently taking place [16,23], that patients are often not properly educated about screening [23,24], and that individuals face biases that may interfere with making an informed decision [25-27]. Clinicians have been slow to adopt the IDM and SDM approaches and as a result they are currently underuti- lized. Practical issues, such as the time required for a detailed discussion of clinical options with patients, have limited the adoption of SDM or IDM [16]. Clinicians under heavy time constraints may find it quicker and easier to order a PSA test than to carefully counsel the patient. Fear of malpractice litigation or financial incen- tives inherent in the health care system have also likely hindered the adoption of IDM/SDM by clinicians. In a recent random survey of 375 men aged 40 and older who had either discussed PSA testing or had a PSA test in the previous two years, only 55% of men were asked their pre- ference for screening [23]. In a small random sample of the medical charts of elderly patients in the VA study [28], only 4% of ordered PSA tests were reported to be requested by patients. Another barrier to decision making is that patients often lack knowledge of prostate cancer and screening tools and are not fully informed of the risks and benefits of screening [24]. A recent survey demonstrates a lack of