National evidence on the use of shared decision making in prostate-specific antigen screening

Abstract

Purpose: Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making-a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.

Methods: A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics.

Results: Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%-90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%-43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared decision making.

Conclusions: Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in nonscreened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening.

Keywords: decision making; mass screening; prostate-specific antigen.

Figure 1

Study population of men aged 50–74 years, National Health Interview Survey, 2010.

Figure 2

Extent of shared decision making by intensity level of PSA screening, 2010 National Health Interview Survey PSA=prostate-specific antigen. Notes: Extent of shared decision making (unadjusted percentages) according to the physician’s discussion of the following elements: advantages, disadvantages, and uncertainty. Fully informed is discussion of all elements. Partially informed/shared (pros+cons/uncertainty) is discussion of advantages and disadvantages or advantages and uncertainty. Partially informed/shared (pros-only) is discussion of advantages only. Partially informed/shared (cons-only) is discussion of disadvantages only, disadvantages and uncertainty, or uncertainty only. Fully uninformed/unshared is no discussion of decision-making elements. PSA screening intensity levels are as follows: no screening = no past history; low-intensity = 1–3 tests in past 5 years; high-intensity = 4–5 tests in past 5 years.