Improving the quality of decision-making processes for prostate cancer screening: Progress and challenges

Guidelines recommend that patients be informed about potential benefits and harms from prostate cancer screening and that screening decisions involve a discussion between patients and their physicians.1,2 Despite this consensus, achieving high-quality decision-making processes in practice is difficult. Clinicians function in a time-constrained environment and know that ordering a prostate-specific antigen (PSA) blood test is simple, whereas ensuring that patients fully understand the potential ramifications of entering a screening program is far more difficult and timeconsuming. Explaining such concepts as biopsy threshold, false-positive results, overdiagnosis, and uncertainty about magnitude of benefit is challenging and cannot be done quickly. Given this complexity and the competingdemands inprimary care, it is not surprising that real-world decisionmaking processes are often suboptimal.3 Indeed, in a nationally representative surveyofmenwhofaced thedecisionabout prostate cancer screening, 30% reported having no discussion with a physician before undergoing PSA testing. Evenwhen thedecisionwasdiscussed, 71% reported that providers communicated thebenefits of screening; only 32%said that downsideswere addressed. Although amajority feltwell informed about screening, 48% failed to correctly answer any of the 3 knowledge questions about prostate cancer risk or predictive value of PSA testing, suggesting problems with misinformation and overconfidence.3 Decision aids are potentially valuable tools that can help improve decision-making processes by ensuring that patients receive accurate information and can incorporate their values into the medical plan.4 Previous studies of PSA decision aids have shown that they can increase knowledge about prostate cancer, reduce decisional conflict, and improve satisfaction.5 However, the studies have generally been small andshort indurationandhavehadmixed results regarding the effect of decision aids on screening test completion. Fewhave directly compared different formats, such as print vs webbased designs. In this issue of JAMA Internal Medicine, Taylor and colleagues6 present findings of, to our knowledge, the largest clinical trial of a PSA decision aid to date. They randomized 1893 men to receive a print-based decision aid, a web-based decisionaid, ornodecisionaid (usual care) andobserved them for 13 months. They found that men who viewed either the printorweb-baseddecisionaiddemonstratedmodestlyhigher knowledge scores regarding prostate cancer and had less decisional conflict 1 month following the intervention. Importantly, theyalso foundthat theseeffectspersistedat 13months, suggesting thatmen retained the knowledge gained by viewing the decision aids and internalized a reduced sense of conflict fromviewing them.The investigators also found that improved decisional satisfaction persisted at 13 months among recipients of the print decision aid but not among recipients of the web-based version. The rate of prostate cancer screening among all participants over the 13 months remained virtually unchanged (at 59%), and neither the print nor thewebbaseddecisionaidhadanyeffect on screening rates compared with usual care. These findings have several implications. First, decision aids can have more than a transient effect on patients’ knowledge, perceived uncertainty, and satisfaction regarding medical decisions. As the authors suggest, this has implications for informing decisions that patients face recurrently (eg, prostate or breast cancer screening). Second, web-based, interactive media are not inherently better than noninteractive media for conveying information about medical decisions. Knowing this may help increase the reach of decision aids because noninteractive materials are less expensive to produce and may be easier to disseminate. This study also points to important challenges in defining and achieving high-quality decision-making processes for prostate cancer screening. The intervention groups demonstrated modest increases (2.5 points on an 18-point scale) in prostate cancer knowledge. However, although statistically significant, it is unclear how relevant this knowledge was to informed decision making or whether it was sufficient to overcome prior misunderstandings regarding potential benefits and harms from screening. Knowledge domains measured in this study (awareness of prostate cancer screening controversy, risk factors, benefits and limitations of prostate cancer treatment, and natural history) may not represent the essential knowledge needed for an informed screening decision. For example, increasing awareness of prostate cancer risk factors may actually worsen already biased risk perceptions. Admittedly, achieving consensus regarding the appropriate body of knowledge needed for making an informed screening decision is difficult. However, many would agree that this knowledge includes understanding one’s risk of death from prostate cancer (which is lower than most men believe); the likelihood that screening will contribute to reducing this risk (which is, at most, small); that screening increases the likelihood of experiencing important harms, including invasive procedures engendered by false-positive results, overdiagnosis and treatment of clinically unimportant cancers, impotence, and urinary incontinence; and that Related article page 1704 DecisionMaking in Prostate Cancer Screening Original Investigation Research