Many doctors insulate their patients from the complexities surrounding the PSA test, and instead decide on their own whether to screen for prostate cancer or not, a new study finds.
Almost two-thirds of older men surveyed said their doctors hadn't discussed the advantages and disadvantages of the PSA (prostate-specific antigen) screening test. And most of those who weren't informed about the test's risks and benefits were men who were not screened.
Study lead author Dr. Paul Han said it's easy to "wave the banner of informed decision-making" with regard to bringing patients into the discussion of their own prostate health. On the other hand, "it's difficult to put it into practice," added Han, staff scientist with the Center for Outcomes Research and Evaluation at Maine Medical Center in Portland. "There's so much complexity and uncertainty."
The PSA blood test, which is frequently given to men starting at age 50, can turn up signs of prostate cancer.
"There's certainly evidence that the test can be beneficial to some men, but the evidence is conflicting, and not all the studies agree," Han said.
The problem is that prostate cancer isn't always dangerous, and it's difficult for physicians to figure out whether it needs treatment or not. On the plus side, if cancer is found early, it may be easier to treat. On the negative side, unnecessary treatment can be harmful.
Underscoring the debate over the value of PSA testing, the American College of Physicians unveiled new guidelines in April that recommend that men between 50 and 69 years old should discuss the limited benefits of the test with their physicians.
According to Dr. Robert Ferrer, vice chair for research in the department of family and community medicine at University of Texas Health Science Center at San Antonio, one death is prevented for every 1,000 men who have PSA screening. "The rate of prostate cancer death is five out of 1,000 men among those who went unscreened, and four in 1,000 among those screened," said Ferrer, co-author of a commentary accompanying the study.
To complicate matters, treatment side effects include incontinence and impotence. But some men are unwilling to wait to see if the cancer worsens, Han said. "Few men opt for watchful waiting," Han noted. "It's hard to know that you have cancer in you and you're not doing anything definitive or active about it."
About one of every six men in the United States will be diagnosed with prostate cancer during his lifetime, and nearly 30,000 will die of the disease this year, according to the American Cancer Society.
In the new study, published in the July/August issue of Annals of Family Medicine, researchers examined the results of a 2010 survey of more than 3,400 U.S. men aged 50 to 74. Sixty-four percent said they'd had no discussions with their physicians about the pros and cons of PSA tests.
Of the total, 44 percent had never been screened. The majority of those, 88 percent, said they hadn't talked about the advantages and disadvantages of the tests with their doctors.
Discussions were much more common among the men screened most often -- nearly annually -- who accounted for one-quarter of the total. Of those, 39 percent said they hadn't had talks with their doctors about the risks and benefits.
Ferrer said he suspects that physicians don't talk about the tests because they've become so routine. Also, it's only recently that the medical community has begun to discuss the possible harms that come from unnecessarily treating prostate cancer, he said.
Should patients even be in the decision loop since the pros and cons of PSA tests are so complex? Ferrer said yes.
He believes doctors have "a duty to help patients understand in situations where there are competing benefits and harms," he said.
"The PSA decision is no more complex than many other health care decisions," he added.
The medical profession needs to find ways to educate patients even if doctor visits are brief and cluttered with other tasks, he explained.
Ferrer added that clinicians have a responsibility to help patients make decisions consistent with their preferences.