Understanding and Overcoming Barriers to Prostate Cancer Screening Discussions Kelly Fryer-Edwards, PhD University of Washington School of Medicine, Seattle Prostate Cancer Screening Rates Higher than Expected Statistics Canada, 2003; Canadian Cancer Society 2006 Prostate Cancer Screening even higher in the U.S. ► National 2001 BRFSS data indicates: Men were more likely have ever been screened for prostate (75%) than colorectal cancer (63%) Men were more likely to have current prostate screening (57%) than current colorectal cancer screening (48%) 56% of men age 80+ had current PSA test Only counted PSA as prostate cancer screening (did not include DRE in analyses) Sirovich BE et al. JAMA 2003;289(11):1414-1420 Cultural inclination toward cancer screening ► Belief that: cancer is bad screening is good tests can give us clear answers we can prevent cancer if we find it. ► Therefore, why shouldn’t we screen for prostate cancer? See HG Welch, 2004 At the Front Lines of Screening General Practitioners worry: How to manage cancer fears? How to provide the best care? How to give guidance to patients? How to manage uncertainty? How to avoid malpractice suits? Pressures to Screen ► Advocacy groups Men should have “their cancer” too ► Cancer Societies Need to reduce cancer mortality ► Medical culture More data is always better ► Urologists Primary care is missing diagnoses Some Eye-Opening Statistics • Each urologist has approximately 10 loyal referring PCPs • Average PCP sees 30 patients\day • Approximately 10 are men >50yrs • 100 MEN >50 YRS OF AGE COULD BE SCREENED EVERY DAY N. Baum, Marketing and Practice Management 2000 Income from 100 screened men\day • • • • • • IOVs FU visits UA, PSAs TRUS and Bx Surgery (RPs and Prostate surgery) Other urologic conditions (ED, Vasectomies, Stones, Prostatitis) • Opportunity to treat family and friends Take Home Message • There are a lot of opportunities, i.e., a big pie,” for physicians\urologists in American healthcare • We just need to “grow the pie” Brief Overview of Talk ► What motivates primary care physicians actions regarding PCS discussions? ► What barriers exist regarding PCS discussions in primary care practice? ► What strategies might we try in working toward best screening practices? ► Where are the leverage points? What might make a difference in practice? CDC Project Purpose: Identify challenges in primary care practice for IDM in PCS discussions with goal of improving discussions ► Phase I: 25 interviews Family Medicine = 13; Internal Medicine = 12 Mean years in practice = 13.9 (1-30) Mean clinic half-days/week = 5.2 (1-10) ► Phase II: 7 focus groups (on-going) 5 community practice MDs, 1 residents, 1 NPs CDC Grant No. 3U48 DP0000050-01S1 September 2004 – 2008 Investigators and Key Personnel: Kelly Fryer-Edwards, PhD (PI) Clarence Braddock III, MD, MPH Thomas Gallagher, MD Barak Gaster, MD Peggy Hannon, PhD Staff: Susan Brown Trinidad, MA (mgr) Sylvia Bereknyei, MA Elizabeth Hopley, BA *Work supported in part by the Centers for Disease Control and the National Cancer Institute via Cancer Prevention and Control Research Network Prostate Cancer Screening and Informed Decision Making (IDM) ► Universal prostate cancer screening is not recommended at this time ► Current guidelines are worded differently USPSTF: insufficient evidence to recommend for or against routine screening ACS: testing should be offered to men age 50 and older (45 if high-risk) who have > 10 years life expectancy, with sufficient information about risks and benefits to make an informed decision ► No clear guidelines on exactly what should be included in the discussion The Disconnect PROBLEM LIST: 1. Diabetes, type 2 2. Hypertension 3. Hyperlipidemia 4. Rotator cuff tendonitis 5. Lumbar disc herniation 6. Benign prostatic hyperplasia 7. Depression 8. Obesity 9. Cigarette smoking • • • Where’s the time for such a discussion? What exactly are the risks and benefits? How do I elicit my patient’s values? Looking for Leverage Points: Physician Beliefs about IDM for PCS ► “Test or be sued” What would persuade a physician that his/her risk of being sued was quite low? ► “Cancer screening is good” What will counterbalance this cultural belief? ► “Uncertainty is bad” How can a physician help his/her patients tolerate or appreciate uncertainty? ► “Patients come in asking for it” In the face of clear public messaging about benefits of testing, how is a physician supposed to deliver a difficult and nuanced message? Looking for Leverage Points: Physician Beliefs about IDM for PCS ► “I don’t want to open Pandora’s Box” Is it, or is it not, an inevitable cascade of events following screening? ► “I only have one spiel” How to help a doc differentially diagnose patients, and vary the spiel based on what the patient needs to understand/hear? What are the ‘money’ questions that will elicit the biggest bang for the buck? ► “I don’t get paid for this” How can we address billing issues to get reimbursed for time spent on decision making? ► “This isn’t a priority” With competing priorities in a visit, where does PCS fit in? ► “It is easier to just order the test” What would convince physicians that a conversation is necessary? The Case that Set the Stage ► Resident sees 53 y.o., well-educated male. ► Presents risks & benefits of prostate cancer screening, documents discussion. No test done. ► Patient changes PCPs. New MD orders PSA without discussion. PSA high, patient diagnosed with advanced prostate cancer. ► Patient sues, plaintiff attorney argues that IDM for prostate CA screening inappropriate. Since test has little risk, should have just ordered it. Plaintiff’s witnesses say SOC is to just order test EBM “cost saving method,” $ saved not worth life lost The Decision ► Resident exonerated Jury thought that there was more than one standard of care - “2 schools of thought” ► Residency found liable, $1 million award Possible concerns about clinic protocols, supervision ► Many practicing physicians see case as highlighting riskiness of IDM for PCS The Facts ► Missed/delayed diagnosis of cancer is common, costly cause of malpractice litigation Breast, colon much more common than prostate ► Probability of individual MD being sued very low Probability of being sued for IDM in PCS lower still Florida 1994-2006: 3376 total claims against PCPs ►9 claims related to prostate cancer Malpractice Fears Cross National Lines ► Canadian physicians 1/4 as likely to be sued as US counterparts ► 2003-4 survey of 2,637 US and Canadian physicians ► For every 100 physicians in your specialty, how many will be sued for malpractice in the next year? Canadian medicine: 4 physicians US medicine: 8 physicians Gallagher et al., Arch Int Med 2006 To Screen or Not To Screen Is Not the Issue Goal of IDM: Foster patient’s understanding, to enable informed participation in clinical decisions Desired outcome: Patient feels the decision about screening is right for him What information is necessary for IDM? ► Chan’s (1998) basic minimum: 17 elements, including: False-positive PSA results can occur False-negative PSA results can occur No one knows whether regular PSA screening will reduce number of deaths from prostate cancer ► Later survey (Chan 2003) suggests that most men do not know these facts Over 90% of men surveyed agreed that regular PSA testing would reduce deaths from prostate cancer Over 75% believed doctors are sure PSA is a useful test The Short Version: ASK – TELL – ASK ► ASK What does the patient already know? What is he most concerned about? ► TELL Fill gaps in knowledge Offer ways different patients respond when faced with this decision ► ASK “Based on what you’ve said, it seems like we should [test/not test]. Does that seem right to you?” Policy Implications ► PSA testing is leading to overdiagnosis Estimated at 29% for whites, 44% for blacks ► Physicians assume they know what men would want, but data shows they do not ► The more men know about the test and the evidence, the less likely they are to pursue PSA screening Etzioni et al. 2002; Krist et al. 2007 Policy Implications ► So, informed decision making helps, but… ► Physicians and patients need guidance on managing uncertainty and fear of cancer ► Communication interventions can help, along with decision-aids, to facilitate efficient conversations ► In the U.S., providing compensation for IDM or extending visit times would help further