Understanding and Overcoming Barriers to Prostate Cancer Screening Discussions

Understanding and
Overcoming Barriers to
Prostate Cancer Screening
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
► Belief
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
Men should have “their cancer” too
► Cancer
Need to reduce cancer mortality
► Medical
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
N. Baum, Marketing and Practice Management 2000
Income from 100 screened
FU visits
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
► 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
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
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
“Cancer screening is good”
What will counterbalance this cultural belief?
“Uncertainty is bad”
How can a physician help his/her patients tolerate or appreciate
“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
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,
► 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
claims related to prostate cancer
Malpractice Fears Cross National
Canadian physicians 1/4 as likely to be sued as US
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
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,
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:
What does the patient already know?
What is he most concerned about?
Fill gaps in knowledge
Offer ways different patients respond when faced
with this decision
“Based on what you’ve said, it seems like we
should [test/not test]. Does that seem right to
Policy Implications
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