Elsevier

European Journal of Cancer

Volume 46, Issue 3, February 2010, Pages 669-677
European Journal of Cancer

Informed decision making on PSA testing for the detection of prostate cancer: An evaluation of a leaflet with risk indicator

https://doi.org/10.1016/j.ejca.2009.11.022Get rights and content

Abstract

Background

Population-based screening for prostate cancer (PCa) remains controversial. To help men making informed decisions about prostate specific antigen (PSA) screening a risk indicator (www.uroweb.org) was developed. This risk indicator is embedded in a leaflet that informs men about the pros and cons of PCa screening and enables calculation of the individual risk of having a biopsy detectable PCa.

Aim

To assess the effect of providing a leaflet including individualized risk estimation on informed decision making of men, i.e. knowledge about PCa and PSA screening, attitude towards undergoing a PSA test and intention to have a PSA test.

Methods

An intervention study among 2000 men, aged 55–65 years, randomly selected from the population registry of the city of Dordrecht, the Netherlands, in 2008. Men were sent a questionnaire on knowledge of PCa, attitude and intention to have a PSA test. Men without a history of (screening for) PCa were sent the leaflet and Questionnaire 2 within 2 weeks after returning Questionnaire 1. Validated health and anxiety measures were used.

Results

One thousand and twenty seven of 2000 men completed Questionnaire 1 (51%), of whom 298 were excluded due to a history of (screening for) PCa. Of the 729 remaining men, 601 completed Questionnaire 2 as well. At the second assessment significantly more men met the requirements of informed decision making (15% versus 33%, p < 0.001), more men had relevant knowledge (284/601, 50% versus 420/601, 77%, p < 0.001) and the intention to have a PSA test had increased (p < 0.001).

Conclusions

Providing information on PCa screening combined with individualized risk estimation enhanced informed decision making and may be used for shared decision making on PSA screening of physicians and patients.

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:

  • 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.

  • 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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