The discussion
The 2001 version of the ACS guideline also recommended shared decision-making; the update emphasizes it more strongly and describes the process in greater detail.
The clinician’s role, according to the guideline, should be “helping men to make this decision by assuring that they have adequate information and by helping them to clarify their values relevant to the decision.”
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Although the level of detail provided should be tailored to the patient’s individual needs and capacities, the guideline specifies core elements of information, which should include the following:
- Prostate cancer is an important health concern
- Screening with PSA alone or with PSA and DRE detects cancer at an earlier stage than otherwise possible
- Screening may reduce the risk of dying from prostate cancer, but the evidence is conflicting, and there is no expert consensus on the value of screening
- PSA and DRE tests may produce false-positive or false-negative results, which can result in unnecessary anxiety and additional testing or missed cancer
- Abnormal PSA or DRE results commonly require prostate biopsy, which can be painful, may lead to complications and sometimes miss significant cancer
- If cancer is detected, it is currently impossible to predict which men will likely benefit from treatment, and who will have died from unrelated causes whether or not they were treated
- Treatments commonly used today may lead to urinary, bowel, sexual and other health problems, which in some cases are severe and permanent
- Not all men whose prostate cancer is detected require immediate treatment. For some, “active surveillance” with periodic blood tests, biopsy or other testing may safely determine when, if ever, treatment is necessary.
The process of clarifying values helps men look at pros and cons of screening in light of what is important to them, how they feel about risk and uncertainty and their attitude toward health care. This discussion might include reasons why men decide for or against screening and hypothetical scenarios to illustrate them.
Like most guidelines, the ACS document includes a review of the evidence behind its recommendations. Here, summaries of studies on the risks and benefits of screening, harms associated with early detection and the effects of various treatments also provide material for a more informed discussion.
Print, web-based or CD-based material may be effective adjunctive tools to help patients make informed decisions. Making such decision aids available for men to review in advance may foster more efficient discussions within the time constraints of a primary-care practice, Brooks noted.
The ACS guideline includes a list of decision aids issued by reputable organizations and available online. Most of these are also available on the ACS website.2
