Evelyn C. Y. Chan

Informed decision making: what is its role in cancer screening?

Interest in informed decision making (IDM) has grown in recent years. Greater patient involvement in decision making is consistent with recommendations to improve health care quality. This report provides an overview of IDM; clarifies the differences between IDM, shared decision making (SDM), and informed consent; and reviews the evidence to date about IDM for cancer screening. The authors also make recommendations for research. We define IDM as occurring when an individual understands the disease or condition being addressed and comprehends what the clinical service involves, including its benefits, risks, limitations, alternatives, and uncertainties; has considered his or her preferences and makes a decision consistent with them; and believes he or she has participated in decision making at the level desired. IDM interventions are used to facilitate informed decisions. The authors reviewed the evidence to date for IDM and cancer screening based primarily on published meta‐analyses and a recent report for the Centers for Disease Control and Preventions Guide to Community Preventive Services. IDM and SDM interventions, such as decision aids, result in improved knowledge, beliefs, risk perceptions, and combinations of these. Little or no evidence exists, however, regarding whether these interventions result in 1) participation in decision making at a level consistent with patient preferences or 2) effects on patient satisfaction with the decision‐making process. These variables generally either were not assessed or were not reported in the articles reviewed. Results of interventions on uptake of screening were variable. After exposure to IDM/SDM interventions, most studies showed small decreases in prostate cancer screening, whereas four studies on breast and colorectal cancer screening showed small increases. Few data are available by which to evaluate current practices in cancer screening IDM. Patient participation in IDM should be facilitated for those who prefer it. More research is needed to assess the benefits of IDM/SDM interventions and to tailor interventions to individuals who are most likely to desire and benefit from them. There are many system barriers to IDM/SDM and few tools. More work is needed in this area as well. In addition, research is needed to learn how to incorporate IDM into ongoing clinical practice and to determine whether there are unintended negative consequences of IDM. Cancer 2004.

What should men know about prostate-specific antigen screening before giving informed consent?

PURPOSE Since prostate-specific antigen (PSA) screening is controversial, some authorities recommend that patients give informed consent before testing. We identified and compared what facts experts and patients thought men should know. SUBJECTS AND METHODS We recruited a Delphi panel of national experts (6 urologists and 6 non-urologists) and conducted 6 focus groups of couples (48 subjects) with 24 screened and unscreened men from a university hospital. We ranked key facts that experts and couples thought men ought to know before consenting to PSA screening and conducted a multidisciplinary focus group to help interpret the findings. RESULTS All participants would disclose that false positive and false negative results can occur and that it is not known whether PSA screening reduces prostate cancer mortality. The 12 experts would disclose the uncertain benefits of treating early, localized prostate cancer. All 24 couples would disclose that the PSA test is a blood test and that patients may worry about results. The 6 urologists would disclose that prostate cancer is often incurable when symptoms appear; the 6 non-urologists, that it can be asymptomatic. The 12 couples with screened men would disclose that the PSA test can detect cancer sooner than the digital rectal examination; the 12 couples with unscreened men, that PSA testing is controversial. CONCLUSIONS Physicians and patients agree upon some facts that men should know about PSA screening before giving informed consent. However, physicians fail to emphasize other facts that patients find important. Physicians may differ by expertise; patients, by experience. Our findings provide content for informed consent for PSA screening, and our method may be useful for other controversial tests.

Informed consent for cancer screening with prostate-specific antigen: how well are men getting the message?

OBJECTIVES This study examined knowledge about prostate-specific antigen (PSA) screening among African Americans and Whites. Because PSA screening for prostate cancer is controversial, professional organizations recommend informed consent for screening. METHODS Men (n = 304) attending outpatient clinics were surveyed for their knowledge about and experience with screening. RESULTS Most men did not know the key facts about screening with PSA. African Americans appeared less knowledgeable than Whites, but these differences were mediated by differences in educational level and experience with prostate cancer screening. CONCLUSIONS Public health efforts to improve informed consent for prostate cancer screening should focus on highlighting the key facts and developing different approaches for men at different levels of formal education and prior experience with screening.

Physician Perspectives on the Importance of Facts Men Ought to Know About Prostate-specific Antigen Testing

AbstractOBJECTIVE: To determine physicians’ rating of the importance of key facts men ought to know about prostate-specific antigen (PSA) screening and whether there are differences by specialty. PARTICIPANTS: A nationwide random sample of internists, family physicians, and urologists stratified by physician specialty from The Official ABMS Directory of Board-Certified Medical Specialists 2000 Edition. MEASUREMENTS: Internists (N=139), family physicians (N=160), and urologists (N=151) were asked to rate how important it is for men to know 17 facts about PSA screening using a 5-point Likert scale. MAIN RESULTS: Of 769 eligible physicians, 450 responded, for an overall response rate of 59%. Urologists and nonurologists differed in rating how important it was for men to know 9 of the 17 key facts. Eight of the nine statements that urologists and nonurologists disagreed upon concerned facts reflecting uncertainty. Nonurologists were more likely than urologists to rate facts reflecting uncertainty as highly important for men to know. These included statements about prostate cancer risk, screening with PSA, and treatment. CONCLUSIONS: Despite professional guidelines supporting informed decision making, the importance of facts men ought to know about PSA testing differ by physician specialty. Systematic differences may reflect differences in professional guidelines about PSA testing.

A community-based intervention to promote informed decision making for prostate cancer screening among Hispanic American men changed knowledge and role preferences: A cluster RCT

OBJECTIVE We assessed the short-term effects of a community-based intervention for Hispanic men to encourage informed decision making (IDM) about prostate cancer screening with prostate specific antigen (PSA). METHODS All senior social and housing centers in El Paso, TX were randomized to intervention, a group-based Spanish language educational program facilitated by promotores (12 centers; 161 men) [Is], or to control, promotores-facilitated diabetes video and discussion (13 centers; 160 men) [Cs]. RESULTS Participants had low levels of schooling and baseline knowledge; 44% reported previous PSA testing. At post-test, the Is made large knowledge gains, increased their understanding that experts disagree about testing, shifted toward more active decision making roles, were more likely to believe that it is important to weigh the advantages and disadvantages of screening and to anticipate potential screening outcomes in making a decision, and were less likely to consider the screening decision easy. The Is did not change in their screening intention or the belief that choosing not to be screened could be a responsible choice. CONCLUSIONS A community-based intervention to support IDM for prostate cancer screening can increase knowledge and may promote more active involvement in decision making about prostate cancer screening. Such an approach can increase knowledge and may promote more active involvement in decision making about prostate cancer screening. PRACTICE IMPLICATIONS It is feasible to develop and implement a community-based intervention program to promote IDM for prostate cancer screening.

Implementing an intervention to promote colon cancer screening through e-mail over the Internet: lessons learned from a pilot study.

Background:Colon cancer screening (CRCS) tests are underused. Multiple CRCS options may confuse patients and lead to inaction. E-mail between patients and physicians may raise awareness about CRCS and allow physicians to answer questions about test options. Objectives:To develop and implement an electronic intervention, the InterNet LETter (NetLET), to increase interest in and use of CRCS among patients with and without e-mail access at home or work. Research Methods:During 2004–2005, 97 patients over 49 years old were recruited during a clinic visit. Patients with e-mail at home or work were assigned to the private access arm; patients without e-mail but willing to use the public library system were assigned to the public access arm. Within each arm, patients were randomized to the NetLET or control group. The NetLET consisted of a personalized e-mail from the physician reminding the patient to undergo CRCS and providing a link to a webpage with information about CRCS. Control groups were mailed a reminder letter from their physician. All were mailed a fecal occult blood test (FOBT) kit. Results:In the public access intervention group, only 1 of 11 patients viewed the NetLET. In the private access intervention group, 10 of 42 viewed it. Eleven of 42 (26%) private access intervention group participants, and 8 of 35 (23%) private access control group participants returned an FOBT. No public access intervention group patients, but 3 of 9 control group patients, returned an FOBT. Conclusions:We concluded that it was not feasible to implement the NetLET, but reasons for lack of success differed for the private and public access arms.

What is needed for informed decisions about prostate cancer screening : perspectives of African-American and Hispanic men

Professional guidelines suggest that men should learn about risks and benefits of screening to make informed decisions consistent with their preferences. We used concept mapping to investigate views of informed decision making (IDM) of minority men. Statements about what men need for IDM about prostate cancer screening were sorted by similarity and rated for importance by 16 Hispanic and 15 African-American men. Multidimensional scaling and cluster analysis were used to develop a concept map for IDM. The 10-cluster solution was selected. The clusters rated most important were labeled Future Considerations, What to Know and Decision to Make. Clusters labeled Social Support and Sharing Perspectives depicted social aspects of the decision and were intermediate in importance. There was strong correlation in relative importance ratings of clusters by African-American and Hispanic men. However, African-American men gave higher importance ratings than Hispanic men. Concept mapping, a method with strong participatory elements, was useful in identifying conceptual frameworks for IDM of African-American and Hispanic men. Health education to support IDM requires some shifts in focus and strategy. It is important that interventions with minority men build upon a strong conceptual framework.

Brief report: Physicians and their personal prostate cancer-screening practices with prostate-specific antigen - A national survey

AbstractBACKGROUND: There is inconclusive evidence that prostate cancer screening with prostate-specific antigen (PSA) reduces mortality. Although PSA testing is widespread, it is unknown how many physicians have taken the PSA test themselves. OBJECTIVE: To determine the prevalence of PSA testing among physicians. DESIGN: Cross-section survey. SUBJECTS: A nationwide stratified random sample of urologists (response rate 61%, n=247), Internists (response rate 51%, n=273), and family physicians (response rate 64%, n=249) were surveyed by mail in 2000. After excluding female respondents and men who either reported a positive history of prostate cancer or did not respond to that query, there were 146 urologists, 96 Internists, and 118 family physicians. MEASUREMENTS: Whether physicians had undergone prostate cancer screening with PSA. RESULTS: Eighty-seven percent (155/178) of male physicians aged, 50 and older and 21% (31/150) of white male physicians under age 50 reported having had a PSA test. More urologists than nonurologists in both age groups reported having had a screening PSA test. CONCLUSION: Most physicians aged 50 and older report undergoing PSA testing. This may reflect a belief in its efficacy and contribute to its widespread use.

BRIEF REPORT: Physicians and Their Personal Prostate Cancer‐screening Practices with Prostate‐specific Antigen

AbstractBACKGROUND: There is inconclusive evidence that prostate cancer screening with prostate-specific antigen (PSA) reduces mortality. Although PSA testing is widespread, it is unknown how many physicians have taken the PSA test themselves. OBJECTIVE: To determine the prevalence of PSA testing among physicians. DESIGN: Cross-section survey. SUBJECTS: A nationwide stratified random sample of urologists (response rate 61%, n=247), Internists (response rate 51%, n=273), and family physicians (response rate 64%, n=249) were surveyed by mail in 2000. After excluding female respondents and men who either reported a positive history of prostate cancer or did not respond to that query, there were 146 urologists, 96 Internists, and 118 family physicians. MEASUREMENTS: Whether physicians had undergone prostate cancer screening with PSA. RESULTS: Eighty-seven percent (155/178) of male physicians aged, 50 and older and 21% (31/150) of white male physicians under age 50 reported having had a PSA test. More urologists than nonurologists in both age groups reported having had a screening PSA test. CONCLUSION: Most physicians aged 50 and older report undergoing PSA testing. This may reflect a belief in its efficacy and contribute to its widespread use.

Acute Renal Failure Secondary to Angiotensin II Receptor Blockade in a Patient with Bilateral Renal Artery Stenosis

A 54‐year‐old man with diabetes mellitus, peripheral vascular disease, and hypertension was admitted to the hospital for an acute exacerbation of chronic heart failure. Therapy with intravenous furosemide and oral losartan 100 mg twice/day was begun. Ten days later, the patients blood urea nitrogen and serum creatinine levels rose and peaked at 110 and 6.0 mg/dl, respectively. His serum potassium level increased to 5.7 mg/dl, urine output dropped to 400 ml over 24 hours, and mental status changes occurred. Magnetic resonance angiography revealed bilateral renal artery stenosis. After losartan was discontinued and hemodialysis was performed for 3 consecutive days, the patients renal function returned to his baseline level. Reports in the medical literature reinforce the importance of recognizing that angiotensin‐converting enzyme inhibitors should be used with caution in patients with bilateral renal artery stenosis. However, the literature is not as definitive about using of angiotensin II receptor blockers (ARBs) in these patients. Our patients experience suggests that ARBs should be used with caution in patients with bilateral renal artery stenosis. Clinicians should be aware that renal failure might occur when using ARBs in these patients.