The US Preventive Services Task Force (USPSTF) has issued a controversial recommendation against routine screening for prostate cancer using the prostate-specific antigen (PSA) test.
Following the release of a draft version of that recommendation, Craig Pollack and his colleagues asked 114 primary care doctors whether they intended to change their practice. The interesting case here is the intentions of the 56 (49%) doctors who agreed with the USPSTF, because there is no reason to expect that those who did not agree would change their views. Of those,
even among those clinicians who agreed with the draft recommendations, fewer than half (41.1%) stated that they would no longer order routine PSA screening or be much less likely to do so.
Should this bother us? If the USPSTF is right, which is of course arguable, then continued routine PSA screening will harm a significant number of men and benefit very few.
However, framing this issue simply as a matter of physician decision leaves the patient out of discussion. Dr. Michael Barry believes that "there will be informed patients who will still want a PSA test, due to risk factors or other personal reasons." Perhaps the physicians who agree with the USPSTF are thinking of such patients. Should a physician who believes that the test is on balance likely to be harmful accommodate such a request? Surgeons do not perform amputations of healthy limbs, even though there are patients who want these procedures.
Let's suppose that the physician was able to explain to the man the likely odds of benefit (extension of life as a result of prevention of prostate cancer) and harm (incontinence, sexual dysfunction, surgical risks), and that there were no circumstances that identified the man as being at elevated risk for prostate cancer. Nevertheless, the patient might have a consuming fear of dying of cancer. Is this irrational? Cancer is a difficult way to die. Perhaps the patient believes that the reassurance he would receive from a negative result would outweigh the risk of harm from a positive result. I have chosen not to be screened, but I think that getting a PSA screen is within the space of plausible choices.
So if having fewer routine PSA screens is a desirable goal, and we do not necessarily think that doctors should refuse to supply them, what needs to change? Of course, the primary issues is that most people do not understand the odds of harm and benefit consequent to a screen. If physicians could find ways to convey this information to patients, and refrained from simply ordering the test without fully informing patients, I believe there would be far less demand for the screen.
Bill
I get it. However, your assumption in the last paragraph is doctors have the capacity to do the job. They dont:
http://blogs.hospitalmedicine.org/SHMPracticeManagementBlog/?p=2796
Don Taylor also tweeted this excellent account of docs interpreting the PSA. Outstanding.
http://www.psychologytoday.com/blog/critical-decisions/201205/is-prostate-cancer-screening-truly-harmful
Brad
Posted by: Brad F | 05/28/2012 at 07:50 PM