Thursday, February 14, 2013

Understanding Risks and Benefits of PSA Testing and the Importance of Shared Decision-Making

Prostate-specific antigen (PSA) testing for prostate cancer has long resided in a medical gray area.  It is a simple and quick blood test for a very common cancer, which accounts in large part for its steadfast popularity with doctors, health fairs, and the public.  But its benefits have been demonstrated to be ambiguous - so much so that the U.S. Preventive Services Task Force recommends against routine PSA screening, stating "that many men are harmed as a result of prostate cancer screening and few, if any, benefit."

The data on the lack of clear benefits of PSA testing, combined with real risks - like diagnostic biopsy and treatment for disease that may not have ever become serious or life-threatening - speaks at a minimum to a need for shared decision-making between patient and doctor about getting a PSA test. Yet, a recent study shows that up to 25 percent of MDs order PSA tests without discussing the issue with their patients.

And even in those doctors who do discuss the issue with their patients, how the issue is framed could have a real effect on whether or not patients choose to be screened or not, as a new paper in the Journal of the American Medical Association - Internal Medicine suggests.  When men were presented with a list of the potential risks or benefits clearly linked with "screening" or "no screening," 44 percent chose screening.  However, when the risks and benefits were not linked specifically with "screening" or "no screening," only 20 percent chose the PSA-like screening option.  This suggests that a more neutral presentation of risks and benefits has men weigh things differently than when risk and benefits are linked specifically to PSA screening.

As we've mentioned in previous posts, screening tests often get portrayed to the public much more in terms of their potential benefits than of their potential risks (here), so it's only natural that many people will lean toward choosing screening over no screening, even when the risks are presented clearly.

A screening test with such modest demonstrated benefits and real risks places a great burden on health care providers to fully explain the risks and benefits of PSA testing to their patients and to help them make the best, most well-informed decision possible.

While the test itself is easy to do, helping patients make a fully informed decision about getting tested is likely not.  The two, though, must go hand-in-hand.

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