Men’s reactions to disclosed and undisclosed opportunistic PSA screening for prostate cancer

Screening for prostate cancer by prostate-specific antigen (PSA) testing is contentious.1-5 In a recent systematic review, the US Preventive Services Taskforce concluded:

All protagonists in the public controversy agree that men should make an “informed decision” about whether or not to undergo PSA screening,1,4 and, hence, need to be fully apprised of the arguments for and against it.6-9

It appears that men participate in PSA screening without their full knowledge. Diefenbach et al10 surveyed 369 Californian men for whom there was corroborated evidence of their having had a PSA test in the previous 2 weeks. Only 26.6% recalled being informed at the time of testing that a PSA test was being ordered. Federman et al11 reported that 31% of a sample of 173 men who had had PSA screening 3 months earlier were unaware that a PSA test had been ordered. An Australian study revealed that 38% of men who had had a screening test for prostate cancer during the previous 5 years could not recall their doctor discussing the pros and cons of screening. A further 39% recalled 5 or fewer minutes dedicated to such a discussion.12 While these studies may be affected by recall bias, they suggest that the pros and cons of PSA screening are not adequately discussed with men.

As general practitioners order PSA tests “opportunistically” when requesting other pathology tests,13 it has been argued that patient autonomy is undermined by such an approach, while GPs are increasing the medicolegal risk to themselves.1-4 As men’s views on PSA screening are relatively unknown, we designed a community survey to explore the appropriateness of screening from their perspective.

As reported in detail elsewhere,14,15 we identified 585 potential respondents. Of these, 521 consented to take part (raw response fraction, 89.1%). Of these, seven were found to have had a previous diagnosis of prostate cancer and their responses were excluded. This left a final sample size of 514 respondents.

Selected characteristics of the participants are shown in Box 1. The age distribution of the sample was not statistically different from that of the population of men defining the sampling frame.14 The majority of men were married or living as married (n = 385; 74.9%), were currently employed (n = 361; 70.2%), and usually spoke English at home (n = 448; 87.2%). Just over a third held a university qualification (n = 192; 37.4%).

With respect to men’s preferences for decisional control regarding PSA screening, 173 (33.7%) preferred an “active” role, while 117 (22.8%) preferred a “passive” role. Men answered, on average, 29% of the 14 knowledge questions correctly.

To our knowledge, our study is the first to compare men’s views about “disclosed” and “undisclosed” PSA screening. An overwhelming majority endorsed “disclosed” PSA screening if a GP elected to initiate its inclusion among a battery of serological tests. Ransohoff et al have speculated that GPs are positively reinforced for ordering tests that may potentially diagnose asymptomatic cancer,23 irrespective of the risks involved in such testing. “Undisclosed” inclusion of PSA screening within a battery of tests was significantly more likely to be rejected by the respondents, although nearly half remained convinced of its appropriateness. It would seem that a sizeable proportion of men respect GPs for taking the initiative, regardless of the extent to which GPs give them sufficient information to make an “informed decision”. Younger men were significantly less likely to endorse such an approach, suggesting that older men may be more willing to acquiesce to “paternalistic” GP behaviour and may be more accepting of it.24,25 Older men may also feel more vulnerable about prostate cancer. Men exhibiting more accurate knowledge about prostate cancer and the pros and cons of its early detection were less likely to endorse Scenario 2. “Undisclosed” screening may be less acceptable to men the more aware they become of the scientific uncertainty about the efficacy of PSA screening and the potential adverse consequences of screening.

As decision aids foster patient empowerment as well as improve knowledge,14,26 their wider use might change men’s views about “disclosure” more generally. On the other hand, some level of support for opportunistic screening may persist, even with more transparent discussions between GPs and patients of the pros and cons of screening. While some have conceptualised the decision whether to undergo PSA screening as a “toss-up” between a possible extended life and possible harms of screening,27 some men may always place greater weight on improved life expectancy. While we tried to ensure that our knowledge test assessed men’s knowledge of both the pros and cons of PSA screening, we accept that there is no “gold standard” for such measures and others may seek to emphasise different aspects.

The high response rate and random selection of participants from the community are strengths of our study. However, as the sample was recruited from an urban area, the findings may not be generaliseable to all Australian men. While order effects within our CATIs may also have biased our results, the shift in men’s views from Scenario 1 to Scenario 2 was substantial, suggesting our findings were not produced by artefacts in study design.

In future research, we recommend that scenarios could be posed in which GPs are depicted as either informing or not informing men of the pros and cons of PSA screening. Other scenarios could elicit views about various methods to assist men to make an informed choice, including consent forms, mandatory disclosure (as required for HIV testing) or “cooling-off” periods (during which patients are advised to take time to think over their decision). Educating men about the pros and cons of screening may alter their support of opportunistic screening and thus enhance community expectations of the “informed participation” recommended by health authorities.