Information and patient participation in screening for prostate cancer
Introduction
In the past decade, a plethora of medical literature has discussed the controversies surrounding the early detection of prostate cancer. However, little is known about how family physicians trying to practice preventive medicine incorporate this information into their everyday practice. The decision to be screened for prostate cancer is often difficult for the patient to make without a lengthy information sharing session with his physician. Patients also vary in the type and amount of information they want or need to make an informed screening decision. Given the time constraints of a busy clinic, it is appropriate to provide men with information about prostate cancer screening prior to their medical appointment. This would facilitate patient–physician communication, and empower these men to be actively involved in making health care decisions.
The main purpose of this study was to determine whether providing men with information about the early detection of prostate cancer would enable them to assume a more active role in making screening decisions with their family physician. Secondary objectives of this study were to determine if the information intervention would lower levels of anxiety and decisional conflict, and have an effect on the number of men who wish to be screened for prostate cancer. It was hypothesized that men who received the information intervention would report that they had assumed a more active role in making a screening decision, and have lower levels of anxiety and decisional conflict post PHE. It was further hypothesized that mens' and physicians' perceptions of role assumed in making a screening decision would not differ, and that the intervention would not have an effect on the number of men wishing to be screened.
Informed choice occurs when a patient is aware of the potential risks and benefits of choosing to be screened, and that the choice is consistent with his personal values. Advising men about the early detection of prostate cancer is a difficult task given the controversy surrounding this issue. The majority of Canadian family physician practices are guided by The Canadian Task Force guidelines [1]on screening which recommends a DRE (digital rectal examination) be used in men over 50 years. However, increased public awareness of the availability of screening tests such as the PSA (prostate specific antigen) results in family physicians balancing their own views, their patients' expectations, and conflicting guidelines issued by different professional organizations.
It is currently assumed that patients as consumers wish to participate or have the choice of whether they wish to be involved in making health-related decisions with their physician. It is also assumed that they will select the alternative or make the choice that has the highest value to them. Conflict arises when an individual does not know how to evaluate the benefits and risks associated with a choice. The resolution of conflict is complicated by the presence of uncertainty about the consequences of one's actions, and it is further hindered by the anticipation of dissonance and regret [2]. The decisional conflict that results from making such a choice has also been hypothesized to be positively correlated with levels of anxiety [3]. Tversky and Shafir [2]further argue that the presence of conflict not only influences the psychological state of the decision maker, but can also affect the actual choice. For example, when one option is better than another in all respects, there is no conflict and choice is easy. However, when each option has significant advantages and disadvantages (such as screening and treatment procedures available for prostate cancer), individuals often experience conflict that makes choice aversive and compels them to delay the decision and seek additional information or options. Although lack of information about available alternatives and their consequences has been hypothesized as a contributor to the conflict over decision making experienced by health care consumers 4, 5, little empirical evidence is available to support such a notion.
Investigators have recently reported that American men who were informed about the risks and benefits of being screened for prostate cancer were less willing to undergo PSA screening 6, 7. However, the extent to which Canadian men wish to participate in screening decisions when the outcomes are uncertain is a relatively unexplored area of research. A recent survey of 482 members of the general public in Canada found that the majority (64%) would like to select their own treatment if they developed cancer [8]. This finding suggests that men may want to participate in deciding whether they want to be screened for prostate cancer. The degree to which these men may choose to participate in screening decisions may also be contingent on other variables. For example, males who are older and less educated have been reported to prefer a passive role in medical decision making 8, 9. Davison et al. [10]also found that although the majority of men with prostate cancer preferred to delegate decisional authority to their physician, they wanted to be fully informed.
Providing detailed information to men newly diagnosed with prostate cancer has been shown to increase their satisfaction with their treatment choice and ability to make treatment decisions [11]. Similarly, a nursing information intervention that assisted a group of men newly diagnosed with prostate cancer to obtain the type and amount of information they wanted was found to significantly increase their participation in treatment decision making [12]. Assisting patients to formulate questions to ask their physician has also been shown to increase older medical patients' satisfaction with medical care [13], increase the number of questions asked 14, 15, and increase their understanding and recall of information [15]. Congruency between patients' and physicians' perceptions of the role assumed by the patients in decision making was identified as lacking in current research.
Section snippets
Sample
A consecutive sample (n=100) of men seen at one Winnipeg Family Medical Teaching Centre was recruited for the study. Patients in this clinic are seen by first and second year residents, preceptors, and/or academic staff. Family physicians can order PSA tests in Manitoba and the cost is currently covered by Manitoba Health.
Selection criteria included all men who: had no previous history of prostate cancer; had made an appointment for a periodic health examination; were 50–79 years of age; able
Patient characteristics
The mean age of the 100 participants was 62.1 years; 56% had a high school diploma or more; 86% were married or had a partner; 49% were employed either full or part-time; 84% resided in Winnipeg; 100% were white; and 61% identified Canadian as being their ethnic group. The majority (58%) of men in the control group were employed, and the majority (60%) of men in the intervention group were retired or unemployed. There were no significant differences between the two groups with regard to age,
Discussion
Results of this study have demonstrated that there are positive benefits associated with providing men with information about the benefits and risks associated with being screened for prostate cancer, and encouraging them to assume a more active role in decision making. Men who received the information prior to their PHE assumed a more active role in making a screening decision with their family physician and reported having lower levels of decisional conflict. Similarly, Davison and Degner [12]
Practice implications
The methodology of the Control Preferences Scale was different than previously reported in other studies. We asked men to read through the five statements and pick the one that best described their preferred role in decision making. This method provided a quick way to identify the role each man wished to play in making a screening decision, and an introduction to discuss the other roles that could be assumed. Use of this measurement in conjunction with the information intervention supports
Summary
In conclusion, screening programs carry the highest burden of proof of benefit because by definition they subject asymptomatic patients to the harms of therapy. Until screening for prostate cancer is proven to result in more good than harm, patients should be fully informed about the benefits and risks associated with screening, and be encouraged to exercise personal preference regarding prostate cancer screening. Our intervention offers a clinical model for educating men about the risks and
Acknowledgements
The authors acknowledge the assistance of the physicians, nurses, and clinic staff at the St. Boniface Medical Centre for their assistance in the data collection process. This work was supported by a Postdoctoral Fellowship from the Manitoba Health Research Council to BJD, and by an investigator award from the Medical Research Council of Canada and the National Health Research and Development Program to LFD.
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