Being Screened for Prostate Cancer: A Simple Blood Test?
The virtues of screening men for prostate cancer continue to be debated in political and public health, as well as clinical forums. Science has been unable to accurately predict screening benefits, yet many men are required to make informed decisions about prostate cancer screening. Clinicians' screening practices have been reported, but little research attention has been given to patients' experiences. The purpose of this study was to describe patients' perspectives of being screened and subsequently diagnosed with prostate cancer. Thirty-five Anglo-Australian men were interviewed, and the data were analyzed using ethnographic content analysis. The findings indicated that most participants experienced screening as a continuum of 3 tests, rather than the simple prostate-specific antigen blood test they had often anticipated. Commitment to a definitive diagnosis when abnormality was detected through screening and uptake of active treatment(s) when prostate cancer was confirmed were strongly represented in this study. The findings offer insight to the complex and often rapid sequence of events that can accompany prostate cancer screening. This has implications for the information that needs to be discussed with men before, rather than after prostate cancer screening has commenced.
Apart from nonmelanoma skin cancer, cancer of the prostate is the most commonly diagnosed cancer in Australian men and has the second highest mortality rate attributed to male cancer. Men are often asymptomatic, especially in the early stages, and no specific cause or cure of prostate cancer has been identified. In addition, the factors associated with increased risk of developing the disease (ie, age, ethnicity, and family history) cannot be modified, and the anatomical position of the prostate gland prohibits the self-examination possible for other hormone-dependent cancers such as testicular and breast. The idiopathic characteristics have made it difficult to situate prostate cancer in health promotion frameworks such as risk reduction and health behavior modification, and medical screening is the most likely health promotion application.
Screening involves systematic organized efforts to identify presymptomatic individuals in a population who is deemed to be at sufficient risk of a specific disorder to warrant further investigation. The World Health Organization's criterion for assessing screening is that there should be evidence that screening for a disease, with subsequent early intervention, is effective in improving health outcomes. In the context of prostate cancer screening, the major issue is whether detection of tumors will result in benefits for patients. Prostate cancers do not act predictably and vary from those that are indolent slow-growing tumors that cause few changes to men's lives, to those that are aggressive and lethal. The decision to screen and subsequently diagnose and treat intermediate tumors is particularly challenging because there is no precise way to predict which tumors in this group will be slow-growing or lethal. The highest incidence of prostate cancer occurs in men older than 60 years, and it is perceived as an older man's disease that men die with, rather than of. This makes it arduous to estimate the "value," in terms of extra years of life, afforded by prostate cancer detection through screening.
The digital rectal examination (DRE) has historically been the common prostate cancer screening test. However, in the late 1980s, the prostate-specific antigen (PSA) blood test became available, and between 1989 and 1996, 1.1 million men received PSA testing in Australia. Although governments and medical and cancer councils have never recommended prostate cancer screening in Australia, there is strong evidence that the rates of de facto screening in men older than 50 years, and especially those aged between 60 and 69 years, are remarkably high. General practitioners (GPs) are the main initiators of screening for prostate cancer. One study indicated that 57% of PSA tests completed by GPs were ordered for screening, and another study reported that up to 40% of GPs surveyed believed in the efficacy of PSA screening. Although it is recommended that GPs and patients discuss screening information, including the implications of an abnormal result, before testing, there is little solid evidence on which to base a consensus on how to advise patients about prostate cancer screening. The clinical indicators on which to conduct screening are also unclear, and men with lower urinary tract symptoms (LUTS) are reported to be at no greater risk of prostate cancer than asymptomatic men of the same age. Therefore, the benefits of screening both asymptomatic and men with LUTS are similarly unknown. Medicolegal issues also influence screening practices, and some GPs are concerned that they risked medical negligence if PSA screening is not offered, and prostate cancer is subsequently diagnosed.
Screening tests are also reported to be inaccurate, and neither the PSA nor the DRE is a reliable indicator of prostate cancer. DRE has limited effectiveness in detecting anterior to midline lesions and small lesion prostate cancers, and one study indicated that 72% of DRE-detected abnormalities did not result in a diagnosis of prostate cancer. The PSA has been associated with "false-negative" and "false-positive" test results, and between 67% and 92% of men who have a positive PSA test will undergo follow-up testing only to discover that they do not have prostate cancer. After abnormal PSA and/or DRE screens, the predominant method to definitively diagnose prostate cancer is the transrectal ultrasound biopsy (TRUS-Bx). The TRUS-Bx involves the passing of biopsy needles through the rectal wall to the prostate gland. Tiny pieces of tissue, typically between 6 and 12 samples, are removed from the prostate via the needles. The TRUS-Bx is invasive and has potential side effects, including hemorrhage, septicemia, psychological stress, anxiety, pain, and impotence.
Commonly cited men's health behaviors include men's denial of symptoms or illness and underutilization of healthcare services and health promotion programs including medical screening. Men predominately use "reactive" healthcare behaviors, which typically include responding to illness with the use of some form of self-treatment, asking female partners or friends for advice, and finally seeking professional help. A study of 30 men who had LUTS revealed that 63% (n = 19) of participants waited a considerable period before their cancer risk was assessed with DRE and PSA, and 73% (n = 22) expressed fear about the possibility of having prostate cancer. Specific prostate cancer screening methods are also reported to affect men's decisions to be screened. Men's negative feelings and embarrassment are barriers to being screened with DRE. In contrast, there has been greater interest in PSA screening, which many men perceived as less invasive and more accurate than the DRE. Factors such as spousal opinion and appointment scheduling and reminder cards are also reported to increase the likelihood that men will participate in prostate cancer screening.
The men who participate in regular prostate cancer screening generally assume that they are acting responsibly with respect to promoting their own health and are motivated by the perceived benefits of early detection, reduced mortality, and improved quality of life. However, it is unlikely that all men make informed decisions when consenting to screening procedures. A study of 40 men who were interviewed after pretest counseling indicated that 93% (n = 37) interpreted the counseled information as unfavorable toward PSA. Participants cited underlying beliefs, such as fear of cancer and salient anecdotes and analogies, as reasons to dismiss counseled information about screening. Similarly, another study indicated that men who were knowledgeable about the screening controversy and risks of treatment showed less interest in PSA screening, and uniformed men showed a greater willingness to accept treatment risks and more interest in PSA screening. Clinicians and patients also have divergent understandings and priorities for undertaking screening. For example, clinicians often overestimate the level of patient knowledge and conduct screening tests to detect disease, whereas men generally undertake the same tests to seek reassurance.
When prostate cancer is diagnosed, issues of informed consent arise with regard to treatment options and potential side effects. Active treatments are predominant in the clinical management of prostate cancer, and men who chose watchful waiting are often pressured by family and doctors to have active interventions. Some men have a choice of treatments, and there is an increasing trend toward active patient involvement in treatment decision making. A study of 119 men showed that, in general, men did not use information comprehensively or systematically when making treatment decisions, and half of the participants deferred decision-making responsibility to their clinician. There is also strong evidence that specialists overwhelmingly recommend the treatment they themselves deliver-urologists recommend prostatectomy, and radiation oncologists recommend radiation therapy.
In summary, prostate cancer screening policies and clinical practice continue to inform, and to be informed by, ongoing epidemiological and biomedical research. The results of the US and European randomized controlled trials on prostate cancer screening will be available on 2008; however, even if screening benefit is detected, the need for men to make fully informed decisions will remain.
Abstract and Introduction
Abstract
The virtues of screening men for prostate cancer continue to be debated in political and public health, as well as clinical forums. Science has been unable to accurately predict screening benefits, yet many men are required to make informed decisions about prostate cancer screening. Clinicians' screening practices have been reported, but little research attention has been given to patients' experiences. The purpose of this study was to describe patients' perspectives of being screened and subsequently diagnosed with prostate cancer. Thirty-five Anglo-Australian men were interviewed, and the data were analyzed using ethnographic content analysis. The findings indicated that most participants experienced screening as a continuum of 3 tests, rather than the simple prostate-specific antigen blood test they had often anticipated. Commitment to a definitive diagnosis when abnormality was detected through screening and uptake of active treatment(s) when prostate cancer was confirmed were strongly represented in this study. The findings offer insight to the complex and often rapid sequence of events that can accompany prostate cancer screening. This has implications for the information that needs to be discussed with men before, rather than after prostate cancer screening has commenced.
Introduction
Apart from nonmelanoma skin cancer, cancer of the prostate is the most commonly diagnosed cancer in Australian men and has the second highest mortality rate attributed to male cancer. Men are often asymptomatic, especially in the early stages, and no specific cause or cure of prostate cancer has been identified. In addition, the factors associated with increased risk of developing the disease (ie, age, ethnicity, and family history) cannot be modified, and the anatomical position of the prostate gland prohibits the self-examination possible for other hormone-dependent cancers such as testicular and breast. The idiopathic characteristics have made it difficult to situate prostate cancer in health promotion frameworks such as risk reduction and health behavior modification, and medical screening is the most likely health promotion application.
Screening involves systematic organized efforts to identify presymptomatic individuals in a population who is deemed to be at sufficient risk of a specific disorder to warrant further investigation. The World Health Organization's criterion for assessing screening is that there should be evidence that screening for a disease, with subsequent early intervention, is effective in improving health outcomes. In the context of prostate cancer screening, the major issue is whether detection of tumors will result in benefits for patients. Prostate cancers do not act predictably and vary from those that are indolent slow-growing tumors that cause few changes to men's lives, to those that are aggressive and lethal. The decision to screen and subsequently diagnose and treat intermediate tumors is particularly challenging because there is no precise way to predict which tumors in this group will be slow-growing or lethal. The highest incidence of prostate cancer occurs in men older than 60 years, and it is perceived as an older man's disease that men die with, rather than of. This makes it arduous to estimate the "value," in terms of extra years of life, afforded by prostate cancer detection through screening.
The digital rectal examination (DRE) has historically been the common prostate cancer screening test. However, in the late 1980s, the prostate-specific antigen (PSA) blood test became available, and between 1989 and 1996, 1.1 million men received PSA testing in Australia. Although governments and medical and cancer councils have never recommended prostate cancer screening in Australia, there is strong evidence that the rates of de facto screening in men older than 50 years, and especially those aged between 60 and 69 years, are remarkably high. General practitioners (GPs) are the main initiators of screening for prostate cancer. One study indicated that 57% of PSA tests completed by GPs were ordered for screening, and another study reported that up to 40% of GPs surveyed believed in the efficacy of PSA screening. Although it is recommended that GPs and patients discuss screening information, including the implications of an abnormal result, before testing, there is little solid evidence on which to base a consensus on how to advise patients about prostate cancer screening. The clinical indicators on which to conduct screening are also unclear, and men with lower urinary tract symptoms (LUTS) are reported to be at no greater risk of prostate cancer than asymptomatic men of the same age. Therefore, the benefits of screening both asymptomatic and men with LUTS are similarly unknown. Medicolegal issues also influence screening practices, and some GPs are concerned that they risked medical negligence if PSA screening is not offered, and prostate cancer is subsequently diagnosed.
Screening tests are also reported to be inaccurate, and neither the PSA nor the DRE is a reliable indicator of prostate cancer. DRE has limited effectiveness in detecting anterior to midline lesions and small lesion prostate cancers, and one study indicated that 72% of DRE-detected abnormalities did not result in a diagnosis of prostate cancer. The PSA has been associated with "false-negative" and "false-positive" test results, and between 67% and 92% of men who have a positive PSA test will undergo follow-up testing only to discover that they do not have prostate cancer. After abnormal PSA and/or DRE screens, the predominant method to definitively diagnose prostate cancer is the transrectal ultrasound biopsy (TRUS-Bx). The TRUS-Bx involves the passing of biopsy needles through the rectal wall to the prostate gland. Tiny pieces of tissue, typically between 6 and 12 samples, are removed from the prostate via the needles. The TRUS-Bx is invasive and has potential side effects, including hemorrhage, septicemia, psychological stress, anxiety, pain, and impotence.
Commonly cited men's health behaviors include men's denial of symptoms or illness and underutilization of healthcare services and health promotion programs including medical screening. Men predominately use "reactive" healthcare behaviors, which typically include responding to illness with the use of some form of self-treatment, asking female partners or friends for advice, and finally seeking professional help. A study of 30 men who had LUTS revealed that 63% (n = 19) of participants waited a considerable period before their cancer risk was assessed with DRE and PSA, and 73% (n = 22) expressed fear about the possibility of having prostate cancer. Specific prostate cancer screening methods are also reported to affect men's decisions to be screened. Men's negative feelings and embarrassment are barriers to being screened with DRE. In contrast, there has been greater interest in PSA screening, which many men perceived as less invasive and more accurate than the DRE. Factors such as spousal opinion and appointment scheduling and reminder cards are also reported to increase the likelihood that men will participate in prostate cancer screening.
The men who participate in regular prostate cancer screening generally assume that they are acting responsibly with respect to promoting their own health and are motivated by the perceived benefits of early detection, reduced mortality, and improved quality of life. However, it is unlikely that all men make informed decisions when consenting to screening procedures. A study of 40 men who were interviewed after pretest counseling indicated that 93% (n = 37) interpreted the counseled information as unfavorable toward PSA. Participants cited underlying beliefs, such as fear of cancer and salient anecdotes and analogies, as reasons to dismiss counseled information about screening. Similarly, another study indicated that men who were knowledgeable about the screening controversy and risks of treatment showed less interest in PSA screening, and uniformed men showed a greater willingness to accept treatment risks and more interest in PSA screening. Clinicians and patients also have divergent understandings and priorities for undertaking screening. For example, clinicians often overestimate the level of patient knowledge and conduct screening tests to detect disease, whereas men generally undertake the same tests to seek reassurance.
When prostate cancer is diagnosed, issues of informed consent arise with regard to treatment options and potential side effects. Active treatments are predominant in the clinical management of prostate cancer, and men who chose watchful waiting are often pressured by family and doctors to have active interventions. Some men have a choice of treatments, and there is an increasing trend toward active patient involvement in treatment decision making. A study of 119 men showed that, in general, men did not use information comprehensively or systematically when making treatment decisions, and half of the participants deferred decision-making responsibility to their clinician. There is also strong evidence that specialists overwhelmingly recommend the treatment they themselves deliver-urologists recommend prostatectomy, and radiation oncologists recommend radiation therapy.
In summary, prostate cancer screening policies and clinical practice continue to inform, and to be informed by, ongoing epidemiological and biomedical research. The results of the US and European randomized controlled trials on prostate cancer screening will be available on 2008; however, even if screening benefit is detected, the need for men to make fully informed decisions will remain.