Informed decision making on PSA testing for the detection of prostate cancer: An evaluation of a leaflet with risk indicator
Introduction
Prostate cancer (PCa) is the most common malignancy in men, with the third cause of death in Europe in 2006.1 Population-based screening on PCa remains controversial although it has shown to reduce PCa mortality by 20% in a randomised screening trial (ERSPC).2 This mortality reduction was associated with a high risk of overdiagnosis, i.e. detection of cancers that in the absence of screening would not have been diagnosed within the person’s lifetime. Between 27% and 56% of all cancers detected in the screening arm of ERSPC (section Rotterdam, the Netherlands) can be classified as potentially indolent, for which invasive treatment may not be necessary.3, 4
While lacking more specific biomarkers, the most commonly used screening tool for PCa is the prostate specific antigen (PSA) test, despite its known weaknesses resulting in false-positive and false-negative results.5, 6 The false-positive results create uncertainty7 and ’unnecessary’ additional testing.2 At the same time men are encouraged to consider PSA screening by media reports, social network, experiences with PCa of friends and family.7, 8 A possible way out of this dilemma is the use of multivariable prediction models or nomograms.5 They can improve the diagnostic value of PSA screening by increasing its relative specificity by adding other potential predictive risk factors to the decisional process.5, 9 Based on the screening data from the ERSPC (section Rotterdam, the Netherlands) a multivariable model was developed and translated into a user friendly instrument.10 This ‘Prostate Risk Indicator®’ (PRI®) provides balanced information on the pros and cons of having a PSA test for PCa and enables men and their physicians to calculate the risk of having biopsy detectable PCa. This may support men making informed choices about having a PSA test or not.11, 12, 13
The purpose of this intervention study was to assess the effect of providing a leaflet with individualized risk estimation on informed decision making of men. We used Marteau’s definition of an informed choice, i.e. ‘a choice, that is based on relevant knowledge, consistent with the decision maker’s value and behaviourally implemented’.14
In this study the following hypotheses were tested:
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The number of men who are able to make an informed choice on PSA screening will increase after the provision of a leaflet including an individualized risk estimation.
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The leaflet with risk indicator will have no impact on the generic health related quality of life and the generic anxiety of men.
Section snippets
Study population and procedure
For this study, a random sample of 2000 men, age 55–65 years from the population registry of the city of Dordrecht, the Netherlands, were sent a letter with information about the study and a questionnaire (Questionnaire 1) on PSA screening, in July 2008. Men who returned the completed Questionnaire 1 were sent a paper version of the PRI® including information about PCa and the pros and cons of PCa screening and a risk indicator to calculate their own estimated risk of having PCa. This paper
Respondents’ characteristics
In July 2008, 2000 questionnaires were sent to men aged 55–65, of which 1,027 (51%) were completed and returned. Two hundred and ninety eight men were classed as ineligible since they had previously been PSA tested (n = 282), had been diagnosed with PCa (n = 14) or were outside the required age range (n = 2). Subsequently the leaflet and Questionnaire 2 were sent to the remaining 729 eligible men, of whom 601 men completed Questionnaire 2 (82%) (Fig. 1).
Table 1 shows the characteristics of the
Discussion
After providing information on PCa and individualized risk estimates with a prostate risk indicator, the number of men with sufficient relevant knowledge on PCa improved significantly and their intention to have a PSA test or not better reflected their attitude towards the PSA test. The number of men who met the requirements of informed decision making increased significantly as well.
The concept of informed choice as defined by Marteau and (adaptations of) her attitude scale have to our
Conclusions
The leaflet including a risk indicator enhanced knowledge about pros and cons of PSA screening and PCa, made men less positive towards screening, enhanced informed decision making, and did not adversely affect men in terms of causing anxiety or negatively influencing mental health. After the intervention most men reported no decisional conflict about having a PSA test or not.
The leaflet including a risk indicator promises to be a useful tool for shared decision making on PSA screening of
Conflict of interest statement
None declared.
Acknowledgements
We are grateful to the men of the population of Dordrecht, the Netherlands, for participating in the study. We thank the Regional Public Health Service of Department Southern South-Holland Province for their friendly cooperation. We gratefully acknowledge the Prostate Cancer Research Foundation (SWOP) and Physico Foundation, the Netherlands, for funding our study.
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2018, Patient Education and CounselingCitation Excerpt :In a study exploring the use of an interactive web-based decisional aid for prostate cancer screening, linear regression indicated that greater use of the website was associated with significantly higher knowledge scores (≥30 vs.<30 min) on the website [B = 0.91 (95% CI = 0.40,1.42), p < 0.001] [52]. An intervention using the ‘Prostate Risk Indicator’ leaflet-based decisional aid among educated older men found that significantly more men were classified as having sufficient prostate cancer knowledge two weeks post-intervention (50% vs 77%; p < 0.001) [53]. In an online colorectal cancer decisional aid, 70% of users identified the correct screening age compared to 56.4% at baseline.
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2014, Urologic Clinics of North AmericaCitation Excerpt :Although the decision aids had no effect on screening behavior of those seeking screening services, they contributed to a decrease in interest in PSA testing among those seeking routine care.39 Similarly, studies published since this review have found variable results for choice of PSA testing, with some showing higher levels of PSA testing40 and others showing lower levels.41 These and other decision aids differ widely in methods, such as level of information and balance in presentation, potentially contributing to variation in findings across studies of decision aids.
What influences the decision to participate in colorectal cancer screening with faecal occult blood testing and sigmoidoscopy?
2013, European Journal of CancerCitation Excerpt :While not all of these factors may be modifiable, anxiety is a factor that may be influenced by information provision. Also, tools such as risk calculators may enhance informed decision making about uptake of screening.37 In 20% of non-participants knowledge was insufficient, so this group might benefit from interventions aimed at increasing knowledge.
A calculator for prostate cancer risk 4 years after an initially negative screen: Findings from erspc rotterdam
2013, European UrologyCitation Excerpt :General practitioners and urologists are increasingly confronted with requests for PSA testing. Several risk assessment tools have been developed to support decision making about having a PSA test or prostate biopsy [3,5,16,17]. We recently studied the implementation of the ERSPC risk calculator into clinical practice and found high compliance with respect to performing a biopsy (83%) [18].