Review Article
The decision-making process in prostate cancer screening in primary care with a prostate-specific antigen: A systematic review

https://doi.org/10.1016/j.jgo.2011.04.001Get rights and content

Abstract

Routine use of prostate-specific antigen (PSA) tests for early detection of prostate cancer remains highly controversial, particularly for older patients. It is thus paramount to examine the factors that influence the decision-making process in prostate cancer screening in primary care (PC).

A systematic review was conducted, searching eight databases for articles published – in English, German, French or Dutch – or in press between January 2000 and February 2011 on studies on the self-reported practices and attitudes of primary care physicians (PCPs) with regard to the use of PSA tests as well as older patients' points of view regarding PSA testing. Study selections, data extraction and assessment of the quality of the studies were conducted independently by two reviewers. A taxonomy of factors influencing the decision-making process was developed to support data extraction.

The analysis involved 20 studies conducted in North America and Europe. Screening with PSA represents a routine practice in PC, even for the most elderly patients. The primary drivers of the decision-making process, as acknowledged by both PCPs and patients, are interactions between patients and PCPs and patient characteristics (e.g. high risk, older age). Other factors are related to the PCP (characteristics, working environment, perceived responsibility, knowledge, perception of PSA test) and the patient (awareness).

Even if guidelines are precautious about screening for prostate cancer, using a PSA test in PC is routine practice in a variety of countries. This review has identified factors influencing prostate cancer screening for older adults. The results suggest that multi-component system changes at the physician and patient levels are needed in order to optimize prostate cancer screening practices in PC, particularly for older men who will not benefit from it.

Introduction

With over 217,700 new cases estimated in 2010, prostate cancer is the most commonly diagnosed cancer in men in the U.S. and with 32,050 estimated deaths, the second greatest cause of mortality due to cancer.1

While the prostate-specific antigen (PSA) test can be used to screen men for prostate cancer, evidence on its positive impact on mortality rate is inconclusive. In 2009, two groundbreaking trials[2], [3] reported conflicting results on the benefits of screening for prostate cancer. The European Randomized Study of Screening for Prostate Cancer demonstrated a survival benefit from PSA screening.2 PSA testing reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis.3 In contrast, the Prostate, Lung, Colon and Ovary Cancer Screening Trial found no difference in survival between screening and control groups.4 However, this trial presents some weaknesses such as contamination4 and lack of a protocol-directed biopsy that decrease the strengths of its conclusion. Follow-up is ongoing in both trials and may provide more answers on the impacts of PSA screening. Furthermore, the observation of the screening practices in the U.S.A. provides important information. In fact, since the mid-1980s, the prostate-specific antigen (PSA) blood test has been widely used in the U.S.A., large majority of men with prostate cancer are diagnosed at a localized stage, and the survival rate has increased.1 However, the relative contribution of PSA testing as opposed to other factors, such as improved treatment, is not clear.[5], [6]

In addition, PSA testing remains controversial because it can be a source of harm. The PSA test detects some cancers that are unlikely to ever present clinically during the patient's lifetime (over-diagnosis).7 Many older patients with limited life-expectancy (42% of American men expected to live less than 5 years) report having recently had a PSA screening test8, yet they might not benefit from it as prostate cancer grows slowly.9 One in eight men repeatedly screened will have a false positive result, even when using a relatively high cut-off PSA level.10 Over-diagnosis and false positive results lead to unnecessary treatment that can damage men's quality of life (over-treatment11), and even increase deaths, due to treatment-related death.12 At this point we cannot state that the benefits of screening with PSA outweigh the harm.5 Prostate cancer screening practices thus need to be optimized.

The current guidelines on prostate cancer screening reflect these controversies. They are conflicting within countries and across countries (see Appendix 1). For instance, the U.S. Preventive Services Task Force (USPSTF)13 and committees in the United Kingdom14 and France15 do not recommend screening. Meanwhile, other professional associations in the U.S.[5], [16] and Europe6 consider the decision to screen should be discussed with the patient. Moreover, the USPSTF recommends against screening men 75 years of age and older.13 There is also some controversy in the literature about this strict age cut-off because of the risk of not detecting aggressive prostate cancer in the men who are most likely to have it17 and preventing men with more than 10 years of life expectancy from benefiting from screening.18

Since primary care physicians (PCPs) play a critical role in screening uptake19, it is paramount to examine how PCPs decide to screen for prostate cancer in a context of such major scientific controversies and conflicting guidelines. Given that many guidelines point out the importance of informed decision making, it is also crucial to obtain better knowledge of the older patient's point of view.

We therefore conducted a systematic review of the literature with two objectives: (1) to examine PCPs' self-reported practices and point of view concerning prostate cancer screening with PSA tests, and (2) to assess older patients' points of view regarding PSA testing.

This study constitutes a first step toward developing more appropriate interventions to improve prostate cancer screening practices in primary care (PC).

Section snippets

Literature Search

The review was based on a systematic, comprehensive search of 8 databases (Medline, Web of Science, Cochrane Database of Systematic Reviews, EMBASE, CINAHL, PsychInfo, SocINDEX, Sociofile/Sociological Abstract). Articles published or in press between January 2000 and February 2011 were considered for inclusion. The literature search was performed by one researcher (IV) with the assistance of a librarian. The following four sets of keywords and terms were used in combination:

  • -

    Cancer (neoplasms,

Results

The search yielded 1109 references (see Fig. 1). Applying the inclusion and exclusion criteria, 929 were excluded on the basis of the title and abstract (Kappa: 0.90) and 160 on the basis of the full text (Kappa: 0.95). Twenty articles were retained: 14 studies analysing the PCP's point of view[24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], 5 studies analysing the patient's point of view[38], [39], [40], [41], [42], one study analysing both.43

Discussion

The results of this systematic literature review suggest that although most of the guidelines are cautious about screening for prostate cancer, using a PSA test in PC is routine practice in a variety of healthcare systems, in both North America and Europe.

While PCPs play an important role in decisions on prostate cancer screening,[35], [44] the results of this review suggest that interactions between older patients and physicians are crucial in the decision-making process. Patients are even

Conclusion

Our systematic review revealed that even if guidelines are precautious about screening for prostate cancer, using a PSA test in PC is routine practice in a variety of countries. This review has identified factors influencing prostate cancer screening for older adults: patients' characteristics and interactions between patients and PCPs. It has highlighted the need for multi-component system changes at the physician and patient levels in order to optimize prostate cancer screening practices in

Author Contributions

Conception and design: Isabelle Vedel, Johanne Monette, Howard Bergman

Data collection: Isabelle Vedel, Martine TE Puts, Michèle Monette

Analysis and interpretation of data: Isabelle Vedel, Martine TE Puts, Michèle Monette, Johanne Monette, Howard Bergman

Manuscript writing: Isabelle Vedel, Martine TE Puts, Michèle Monette, Johanne Monette, Howard Bergman

Funding

The work of I. Vedel was supported by the Dr. Joseph Kaufmann, Chair in Geriatric Medicine, McGill University; the Jewish General Hospital; and the Solidage Research Group on Frailty and Ageing. The work of MTE Puts was supported by a post-doctoral research fellowship from the Canadian Cancer Society/National Cancer Institute of Canada. The sponsors played no role in the study design; the collection, analysis and interpretation of data; the writing of the manuscript; or the decision to submit

Acknowledgments

Muriel Gueriton, librarian, provided help with the literature search.

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