Will Evidence on Prostate Cancer Screening Shape Clinical Practice?
By Craig Pollack, MD, MS, MHS, a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholar alumnus (2006-2009), assistant professor of medicine and associate director of the General Internal Medicine Fellowship program at Johns Hopkins University
The United States Preventive Services Task Force, a group never to shy away from controversy, recently released its final recommendations on prostate cancer screening. The Task Force gave prostate-specific antigen (PSA) testing a grade D, indicating that it should be discouraged as part of routine testing. They noted that there were substantial harms associated with testing and subsequent diagnosis and treatment: worry and anxiety; infections from biopsies; incontinence and erectile dysfunction. And the benefits were likely to be small—on the order of 1 life saved for every 1,000 men screened.
However, the recommendations have caused tremendous controversy. Critics question whether the Task Force has appropriately weighed the risks and benefits and balanced the existing evidence. Our research suggests that even those who agree with the recommendations will find it hard to stop screening. We are now working on a set of decision-making tools for primary care providers (PCPs) and patients to minimize unnecessary screening.
With my colleagues at Johns Hopkins University, I fielded a survey to shed some light on what PCPs thought about the recommendations. In the setting of changing recommendations, we wanted to understand whether PCPs believed the recommendations were appropriate. And how would the recommendations change their clinical practice? The survey was fielded in November 2011 when the recommendations were still in draft form.
Our study of 125 providers affiliated with Johns Hopkins Community Physicians found that nearly half agreed with the draft recommendations against routine PSA screening. However, less than 2 percent said that they would stop routine PSA screening entirely. Even among those who agreed, relatively few would be much less likely to order PSA screening.
PCPs in our survey noted several barriers to stopping PSA screening among older men who had been undergoing screening (and among whom 2008 recommendations advise against routine screening). Many PCPs believe that patients expect their health care providers to continue ordering screening. PCPs are worried about the uncertainty associated with stopping screening and lack time to have conversations with their patients. The results highlight the barriers faced by PCPs in implementing recommendations.
Recognizing these challenges, we are currently focusing our efforts on reducing rates of PSA screening that would clearly be considered to have limited value and providing targeted screening recommendations and discussion points. More broadly, a working group led by the Sidney Kimmel Cancer Center at Hopkins is developing interventions that help give PCPs—and their patients—the tools they need to optimize cancer screening so that evidence reaches clinical practice.