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Researchers examine decision aids for prostate cancer screening and patients' attitudes toward screening and treatment

Since the benefits of detecting prostate cancer early in asymptomatic men remain uncertain, professional organizations recommend educating patients about potential harms and benefits of screening. Prostate cancer tends to be very slow growing, and false-positive screens (indicating cancer when there is none) can lead to harmful invasive testing. Two recent studies supported by the Agency for Healthcare Research and Quality focused on decisions and attitudes about prostate cancer screening. The studies are summarized here.

Volk, R.J., Spann, S.J., Cass, A.R., and Hawley, S.T. (2003, May). "Patient education for informed decision making about prostate cancer screening: A randomized controlled trial with 1-year follow-up." (AHRQ grant K02 HS00007). Annals of Family Medicine 1(1), pp. 22-28.

A simple 20-minute educational videotape can influence men's decisions about prostate cancer screening, and appears to promote informed screening decisions, according to this study. The researchers randomized a group of 160 men 45 to 70 years of age with no history of prostate cancer to view or not view (control group) a 20-minute educational videotape about prostate cancer screening before a routine office visit at a family medicine clinic. The men were asked about their screening knowledge 2 weeks after the visit, and 1 year later, they were asked about receipt of prostate cancer screening (either digital rectal exam [DRE] or prostate-specific antigen [PSA] testing), satisfaction with their decision, and screening knowledge.

The rate of DRE did not differ between the two groups. About one-third (34 percent) of men who viewed the videotape and 55 percent of the control group had PSA testing. The videotape appeared largely responsible for the differences observed in screening rates. Men who watched the videotape and said they intended to be screened at 2 weeks after the visit were as likely as men in the control group to report having had PSA testing at 1-year followup (53 vs. 58 percent). However, 12 of the men in the videotape group reported at the 2-week followup that they did not intend to be screened in the following year compared with none of the men in the control group; only 1 of the 12 men had undergone PSA screening at the 1-year followup.

It appears that the informed men were less likely to pursue PSA testing. However, this result may be influenced by ethnicity or risk perceptions. Black men, who have a higher risk of prostate cancer, were more likely to have had PSA testing than white men (56 vs. 28 percent). Satisfaction with the screening decision did not differ between the study groups. Men in the videotape group were more knowledgeable about screening than men in the control group at the 2-week assessment, but the differences declined within a year. A remaining challenge is how to integrate the use of decision aids into routine clinical practice.

Volk, R.J., Cantor, S.B., Cass, A.R., and others (2004). "Preferences of husbands and wives for outcomes of prostate cancer screening and treatment." (AHRQ grant HS08992). Journal of General Internal Medicine 19, pp. 339-348.

Screening men for prostate cancer can lead to a cascade of events, from biopsy to treatment-related complications. Common complications resulting from surgical and radiation treatment of prostate cancer include impotence, urinary incontinence, and bowel problems. These complications can markedly affect a man's quality of life, ability to function, and intimate relationship with his wife. Yet wives feel quite differently about these complications than men do, found this study. Thus, the researchers recommend that both the patient and his partner be involved in making decisions about prostate cancer screening.

The study involved 168 couples in which the husband was a primary care patient and a candidate for prostate cancer screening. Participants were asked about how they viewed certain screening and treatment outcomes and quality of life with advanced prostate cancer. They used a time-tradeoff method to evaluate preference for a particular health state (utility assessment), ranging from 0 for death to 1.0 for perfect health. The couples completed interviews and utility assessments individually and then as a couple. Men evaluated the outcomes of prostate cancer treatment (ranging from incontinence and impotence to rectal and urethral injury) and life with advanced prostate cancer as being far worse than their wives did. Couples' preferences fell between the separate assessments of husbands and wives.

For example, wives rated partial and complete impotence and mild to moderate incontinence as 1.0, indicating that most wives were not willing to trade away any time (of their husbands' life expectancy) to avoid these treatment complications. Most husbands indicated that they would be willing to trade some longevity to avoid these complications. The largest differences in median utilities between husbands and wives were observed for severe incontinence, prostate cancer unresponsive to hormone therapy (for which pain is a concern), rectal injury, hormonally responsive prostate cancer, and complete impotence.

Editor's Note: Another AHRQ-supported study on a related topic (cancer screening) found a low prevalence of colorectal cancer screening in a large medical organization. For more details, see Hawley, S.T., Vernon, S.W., Levin, B., and Vallejo, B. (2004, February). "Prevalence of colorectal cancer screening in a large medical organization." (AHRQ grant K02 HS00007). Cancer Epidemiology, Biomarkers & Prevention 13, pp. 314-319.

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