Prostate Cancer: Educating Men about Informed Decision Making

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Prostate Cancer Educating Men about Informed
Decision Making

• Kathryn Hess, BS
• Outreach Specialist
• Wyoming Comprehensive Cancer Control Program
• Wyoming Department of Health
• Preventative Health and Safety Division

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Prostate Cancer

• Prostate Cancer is the 2nd leading cause of
  cancer death in American men.
• About 1 in 6 men will be diagnosed with Prostate
  Cancer
• Only 1 in every 34 men will die from Prostate
  Cancer
• There are a little over 1.8 million survivors of
  Prostate cancer in America

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Objectives

• To discuss what is known about the risk of
  prostate cancer and its natural history.
• To discuss what is known about the potential
  benefits and potential harms of screening for and
  treating prostate cancer.
• To discuss how primary care clinicians can use
  shared decision making with their patients in
  deciding whether to screen for prostate cancer.

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Incidence Wyoming
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Incidence Trends Wyoming
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Incidence and Mortality Summary Wyoming
2004
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Overall Risk
National Data 2004

• Center for Disease Control - http//www.cdc.gov/ca
  ncer/prostate/prospdf/prosguide.pdf

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Natural History

• Prostate cancer is biologically heterogeneous.
• Some prostate cancers grow slowly and never cause
  symptoms.
• Other prostate cancers are fast growing and
  metastasize quickly.
• Other types grow at a modest pace.

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Prevention

• Known risk factors for developing prostate
  cancer
• Age
• Race/ethnicity
• Family history of prostate cancer
• No agreement on modifiable risk factors

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Screening for Prostate Cancer What is the Big
Deal?
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Screening Tools
Prostate Specific Antigen (PSA)
Digital Rectal Exam (DRE)
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What are the Issues?

• Does screening extend mens lives (are there
  potential benefits)?
• Does screening cause adverse health issues (are
  there potential harms)?
• Do the benefits outweigh the harms?

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Current Screening Guidelines

• USPSTF the evidence is insufficient to
  recommend for or against routine screening for
  prostate cancer using PSA or DRE
• Although screening can find cancer early, it is
  uncertain whether the potential benefits justify
  the potential harms
• Inconclusive evidence that early detection
  decreases mortality

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Benefits of Screening

• PSA screening detects cancers earlier.
• Treating PSA-detected cancers may be effective
  but we are uncertain.
• PSA may contribute to the declining death rate
  but we are uncertain.

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Harms of Screening

• Three issues to consider
• False-positive screening tests.
• Overdiagnosis (men who do not benefit from
  diagnosis).
• Side effects of treatment.

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False Positives of PSA Screening
http//www.health.gov.on.ca/english/providers/pub/
cancer/psa/psa_guide/psa.gif
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Overdiagnosis

• Overdiagnosis is difficult to quantify.
• One recent report estimated that during 19881998
  about 3 of every 10 men aged 6084 diagnosed with
  prostate cancer by PSA testing would never have
  had clinical disease.
• Other studies show even higher percentages of
  overdiagnosis.

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Side Effects of Treatment
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To Screen OR Not Screen?
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Informed Decision Making

• An intervention in the clinical setting in which
  patients and providers collaborate in decision
  making.
• - American Journal of Preventative Medicine

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Informed Decision Making

• Informed decision making means
• Encouraging a patient to participate in the
  decision.
• Helping a patient consider how the evidence fits
  his values and preferences.

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What Should the Patient Know?
Do I know the likelihood of various outcomes?
Do I understand the benefits?
Do I know the potential consequences of my
decisions?
Do I understand the potential harms?
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Benefits of Informed Decision Making

• How the patient benefits
• Takes an active role in his health care.
• Becomes better informed.
• Chooses the option most consistent with his
  personal preferences.
• How the clinician benefits
• Solves a clinical dilemma.
• Informs and involves a patient in his care.

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How to use Informed Decision Making

• These are the key elements
• Provide information Use decision aids.
• Discuss his questions and concerns.
• Discuss why men choose different options.
• Listen and make a joint decision.

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1. Inform Your Patient

• Let him know that the decision is his, with the
  clinicians help.
• Give him information about
• Prostate cancer.
• Screening tests.
• Benefits and side effects of treatment .

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How Can We Inform Patients?

• Decision aids
• Are available in different types Pamphlets,
  videos, Web-based formats.
• Can help achieve different goals
• All inform and promote patient involvement.
• Some help patients see that their preferences fit
  one option better than another.
• Can be used at different times Before, during,
  or after the visit.
• Are available at www.cdc.gov/cancer/prostate

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Why use Decision Aids?

• Evidence suggests such aids help men
• Become better informed.
• Understand their options.
• Understand which option best fits their
  preferences.

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2. Discuss His Questions and Concerns

• Address misconceptions.
• Give him time to think.
• Use more than one visit, if needed.

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3. Discuss Why Men Choose Different Options

• Patient who decided to be screened
• The way I see it, its the best thing weve got
  to protect ourselves from prostate cancer. Even
  if it saves one life, it is worth all of the
  possible side effects of treatment. Im one of
  those people who just likes to know.
• Patient who chose not to be screened
• The problem is we really dont know if it will
  help anyone, and it could hurt people. I think
  Ill wait until we know more.

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4. Listen and Make a Joint Decision

• If he is ready to choose, accept and support his
  decision.
• If he is not ready, put the decision off until
  the next visit.
• If he asks what you would choose, tell him you
  know men who have chosen both options.
• If he is unable or does not want to make a
  decision, give him your recommendation.

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Summary

• Shared decision making is the best current answer
  because
• There is evidence that screening may extend mens
  lives, but the evidence is not conclusive.
• Some men suffer harms from screening.
• How men weigh potential harms and benefits
  depends on the individual.
• Our challenge
• To find ways to help men make their own decisions.

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Resources

• USPSTF
• USPSTF. Screening for Prostate Ca
  Recommendations and Rationale. AAFP 20034
  787-92
• Center for Disease Control
• http//www.cdc.gov/cancer/prostate/
• Wyoming Cancer Surveillance Program
• Wyoming Department of Health
• National Cancer Institute
• www.nci.nih.gov
• American Cancer Society
• www.cancer.org

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Questions?

• Kathryn Hess, BS
• Outreach Specialist,
• Wyoming Comprehensive Cancer Control Program
• Khess_at_state.wy.us
• 307.777.1918