Educating Men About PSA Tests: Tutorials Do the Job
Print and Web-based learning tools that men can
review at home significantly improve informed decision-making about
prostate cancer screening, but they do not affect actual screening
rates, according to new study.
Specifically, these tools, known as decision aids, resulted in significantly improved prostate cancer knowledge and reduced "decisional conflict," compared with usual care, at both 1 and 13 months after the aids were used (P < .001).
The results were published online today in JAMA Internal Medicine.
The study is the largest of its kind to date — with 1893 participants — on prostate cancer screening, which comprises both prostate-specific antigen testing and the digital rectal exam, according to the authors, led by Kathryn L. Taylor, PhD, associate professor of population sciences at the Georgetown Lombardi Comprehensive Cancer Center in Washington, D.C.
Whether or not to get screened is a "difficult decision" for men, in part because of the "mixed evidence" about benefits, Dr. Taylor and colleagues explain. It is a decision in need of educational support. "Most men overestimate the benefits of prostate cancer screening and are unaware of its limitations," they write.
These results are "consistent" with the decision-aid literature for both prostate cancer screening decisions and other medical issues — with one exception, said Richard M. Hoffman, MD, MPH, professor of medicine at the University of New Mexico School of Medicine in Albuquerque, who was not involved with the study.
"Although the current study found no effect on screening rates, a previous meta-analysis of 18 studies showed that receiving a decision aid reduced screening by about 12%," Dr. Hoffman told Medscape Medical News in an email.
Decision aids, which are typically reviewed at home by patients, promote efficiency in the clinic, said Dr. Hoffman, who is also a consultant to the Informed Medical Decision Foundation in Boston.
When a patient reviews the material at home, the clinician can then focus "just on a patient's specific questions, rather than trying to review the entire topic," he noted.
Dr. Taylor and colleagues believe that "work is now needed" to deliver decision aids to more men considering prostate cancer screening.
According to Dr. Hoffman, several factors will "improve uptake," including malpractice protection. "Washington state has passed legislation stating that receiving and discussing a decision aid represents the highest level of informed consent," he said.
Clinicians also need reimbursement for the activity. "The healthcare reform act supports engaging patients in shared decision making (best accomplished by providing a decision aid), but clinicians need to be able to bill for this activity," he explained.
Lasting Improvement
In the randomized study, conducted at 3 Washington, DC–based health systems from 2007 to 2011, 628 men received a print decision aid, 625 used a Web-based interactive version of the same aid, and 626 men received usual care (i.e., no information from clinicians). Of the study cohort, 40% was black and 23% had a high school education or less.
At baseline and 1 and 13 months after participants reviewed their decision aid or received usual care, a telephone interview was conducted to assess participant's knowledge of prostate cancer and related screening (18 true/false questions) and their decisional conflict and satisfaction.
As noted above, at each follow-up,the 2 decision aids resulted in significantly better prostate cancer knowledge and less decisional conflict than usual care.
The protracted period of significantly improved knowledge (up to 13 months) is notable, said Dr. Taylor.
"This is a very important finding, given that only 2 other studies have demonstrated the maintenance of knowledge at 1 year," she told Medscape Medical News in an email. "Because men must continually make the decision about whether to be screened over a number of years, it is important that the materials provided information that was retained."
Among the decision-aid users, the maintenance of high satisfaction was another story.
At 1 month, significantly more participants in the print group than
in the Web group reported high satisfaction (60.4% vs 52.2%; P = .009), as did significantly more participants in the Web (P = .001) and print (P = .03) groups than in the usual-care group (45.5%).
At 13 months, there was no difference in the proportion of participants reporting high satisfaction between the print and usual care groups (55.7% vs 49.8%; P = .06), or between the print and Web (50.4%) groups (P = .10).
Screening rates at 13 months (around 59%) did not differ significantly among groups.
The study authors contend that decision aids do not bias users in any way.
"The decision aids offer neutrality, shown by the fact that they did not influence the screening decision in either direction compared with usual care.... These tools offer flexibility for patients and providers, given the availability of both print-based and Web-based tools," they conclude.
The study was supported by grants from the National Cancer Institute and the Department of Defense. The authors have disclosed no relevant financial relationships.
JAMA Intern Med. Published online July 29, 2013. Abstract
Specifically, these tools, known as decision aids, resulted in significantly improved prostate cancer knowledge and reduced "decisional conflict," compared with usual care, at both 1 and 13 months after the aids were used (P < .001).
The results were published online today in JAMA Internal Medicine.
The study is the largest of its kind to date — with 1893 participants — on prostate cancer screening, which comprises both prostate-specific antigen testing and the digital rectal exam, according to the authors, led by Kathryn L. Taylor, PhD, associate professor of population sciences at the Georgetown Lombardi Comprehensive Cancer Center in Washington, D.C.
Whether or not to get screened is a "difficult decision" for men, in part because of the "mixed evidence" about benefits, Dr. Taylor and colleagues explain. It is a decision in need of educational support. "Most men overestimate the benefits of prostate cancer screening and are unaware of its limitations," they write.
These results are "consistent" with the decision-aid literature for both prostate cancer screening decisions and other medical issues — with one exception, said Richard M. Hoffman, MD, MPH, professor of medicine at the University of New Mexico School of Medicine in Albuquerque, who was not involved with the study.
"Although the current study found no effect on screening rates, a previous meta-analysis of 18 studies showed that receiving a decision aid reduced screening by about 12%," Dr. Hoffman told Medscape Medical News in an email.
Decision aids, which are typically reviewed at home by patients, promote efficiency in the clinic, said Dr. Hoffman, who is also a consultant to the Informed Medical Decision Foundation in Boston.
When a patient reviews the material at home, the clinician can then focus "just on a patient's specific questions, rather than trying to review the entire topic," he noted.
Dr. Taylor and colleagues believe that "work is now needed" to deliver decision aids to more men considering prostate cancer screening.
According to Dr. Hoffman, several factors will "improve uptake," including malpractice protection. "Washington state has passed legislation stating that receiving and discussing a decision aid represents the highest level of informed consent," he said.
Clinicians also need reimbursement for the activity. "The healthcare reform act supports engaging patients in shared decision making (best accomplished by providing a decision aid), but clinicians need to be able to bill for this activity," he explained.
Lasting Improvement
In the randomized study, conducted at 3 Washington, DC–based health systems from 2007 to 2011, 628 men received a print decision aid, 625 used a Web-based interactive version of the same aid, and 626 men received usual care (i.e., no information from clinicians). Of the study cohort, 40% was black and 23% had a high school education or less.
At baseline and 1 and 13 months after participants reviewed their decision aid or received usual care, a telephone interview was conducted to assess participant's knowledge of prostate cancer and related screening (18 true/false questions) and their decisional conflict and satisfaction.
As noted above, at each follow-up,the 2 decision aids resulted in significantly better prostate cancer knowledge and less decisional conflict than usual care.
The protracted period of significantly improved knowledge (up to 13 months) is notable, said Dr. Taylor.
"This is a very important finding, given that only 2 other studies have demonstrated the maintenance of knowledge at 1 year," she told Medscape Medical News in an email. "Because men must continually make the decision about whether to be screened over a number of years, it is important that the materials provided information that was retained."
Among the decision-aid users, the maintenance of high satisfaction was another story.
At 13 months, there was no difference in the proportion of participants reporting high satisfaction between the print and usual care groups (55.7% vs 49.8%; P = .06), or between the print and Web (50.4%) groups (P = .10).
Screening rates at 13 months (around 59%) did not differ significantly among groups.
The study authors contend that decision aids do not bias users in any way.
"The decision aids offer neutrality, shown by the fact that they did not influence the screening decision in either direction compared with usual care.... These tools offer flexibility for patients and providers, given the availability of both print-based and Web-based tools," they conclude.
The study was supported by grants from the National Cancer Institute and the Department of Defense. The authors have disclosed no relevant financial relationships.
JAMA Intern Med. Published online July 29, 2013. Abstract
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