Unwanted control: how patients in the primary care setting decide about screening for prostate cancer

https://doi.org/10.1016/j.pec.2003.12.002Get rights and content

Abstract

Current guidelines recommend shared decision-making to determine whether the prostate-specific antigen (PSA) test should be performed. At a large family medicine practice in suburban Washington, DC, we administered a sequence of patient and physician surveys to examine the desired and actual level of patient control over PSA screening decisions and the circumstances in which they occur. Both before and after visits, patients expressed a preference for a shared approach to the PSA decision, but the actual decision involved a significant shift toward greater patient control. Almost 25% of patients reported greater decisional control than they desired. Fully 30% of the men who wanted a shared approach made the actual decision themselves. Patients prefer a shared approach to the PSA decision but report greater personal control when the decision is actually made. Further research is needed to understand this phenomenon and to better accommodate patients’ desire for shared decision-making.

Introduction

Continued uncertainties about the benefits and harms of screening for prostate cancer [1] have led most medical organizations to eschew blanket recommendations for or against screening and to instead encourage some form of shared decision-making between the patient and physician before testing is pursued [2], [3], [4], [5]. The news media have publicized the consistent message in these guidelines that men should discuss the tradeoffs with their physician and consider personal preferences as a prelude to screening [6], [7].

Relatively little is known, however, about primary care physicians’ capacity to offer such counseling, how often it occurs in practice, patients’ desire to share control over decisions, and how choices are ultimately made. Many view locus of control as a continuum, with complete patient and complete physician control over decisions occupying either extreme. How decisions about prostate screening are distributed across that continuum is unclear. A survey in 1996 suggested that physician control was substantial; more than 50% of men tested for prostate-specific antigen (PSA) had not heard of the test and were unaware that they had received it [8]. Familiarity with PSA has increased since 1996. In some cases the locus of control rests firmly with patients, as when men visit the physician to obtain a PSA test, but an unknown proportion of men prefer a middle ground, seeking background knowledge and professional advice from their physician before making a decision.

Based on evidence that most patients want information about healthcare choices and that a sizable minority want an active role in making decisions [9], [10] considerable work has gone into the development of decision aids to facilitate informed choices [11], [12]. Decision aids for prostate screening have been developed, but most evaluative work has focused on whether they affect knowledge or PSA test-ordering practices [13], [14], [15], [16], [17], [18], [19], [20]. Few studies have examined the larger questions about the prostate cancer screening decision, such as the degree to which patients want to share control, and whether and how such decisions transpire in the clinical encounter.

Preliminary data gathered in a randomized trial enabled us to study these issues. In the first phase of the trial, which aims to measure the effect of a pre-visit decision aid on PSA decision-making, we surveyed 161 primary care patients and their physicians to determine the knowledge, attitudes, and process that accompanied their decisions about PSA screening. We contrasted the information the patients provided in telephone interviews prior to their health maintenance examinations with that obtained in exit surveys completed immediately after the visit.

Section snippets

Setting

The study occurred at a large family practice in Fairfax, Virginia, a suburb of Washington, DC. The practice has an average weekly volume of 1000 visits and schedules 24 min for health maintenance examinations. Men over age 50 comprise approximately 9% of the practice’s clientele. Approximately 70% of adult male patients have a college education and 90% have an annual median family income greater than US$ 50,000 [21].

Sampling frame

The eligible sample was men age 50–70 years who scheduled a health maintenance

Study population

During the study period, 329 men age 50–70 scheduled health maintenance examinations. The research assistant was successful in contacting 202 (61%), and 161 (80%) of these men were enrolled. The 41 men who were excluded planned to obtain blood work before the visit (18), lacked an email address (10), had a history of prostate cancer (6), declined participation (5), or were enrolled in a prostate screening study at another institution (2). Of the 161 men who completed the pre-visit telephone

Discussion

Our study offers insight into the attitudes and process that primary care patients bring to the PSA screening decision. In this cohort of patients we found that 58% came to the health maintenance examination planning to be tested, and testing ultimately occurred in 70% of visits. The PSA test is no longer unfamiliar to primary care patients: 72% of these men had been tested before. These results are consistent with other studies in the United States, which indicate that 75% of men age 50 and

Acknowledgements

The authors thank Annette O’Connor, Robert J. Volk, and Andew M. Wolf for their advice on the study, and B. Joyce Davison, Vikki Entwistle, and an anonymous reviewer for their useful suggestions on the manuscript. We also thank the Virginia Ambulatory Care Outcomes Research Network (ACORN) for providing infrastructure support for the study. Financial support from Joint American Academy of Family Physicians Foundation-American Academy of Family Physicians Grant No. G0113 is acknowledged.

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