Shared decision-making (SDM) is the new hot ticket for choosing a prostate cancer (PCa) treatment. I posted a 2023 blog about the importance of doctor-patient conversations that enable patients to ask questions and share their concerns, while doctors take on the role of neutral educator and empathic listener. This collaboration helps patients avoid treatment regret because they have been fully informed of the advantages and disadvantages of their treatment choice.

SDM is important even before a diagnosis is made. Take the issue of screening. A simple and inexpensive PSA blood test is still the standard for early detection. However, as of 2018 the US Preventive Services Task Force now recommends that men with no known PCa risk factors engage in SDM with their doctors about the benefits and potential harms of screening. Why did the Task Force issue this advisory? Well, for decades an abnormally high PSA result—which could mean PCa or several other noncancerous conditions—quickly led to countless unnecessary biopsies. Like the first domino to fall, these led in turn to biopsy side effects, aggressive treatments and lengthy aftereffects that impact quality of life. Ugh.

In an ideal world, all men would commit to annual wellness visits, and during these visits they would be afforded as much time as necessary for SDM conversations about the merits of PSA testing in their own case. However, a new study suggests use of SDM for PSA testing is spotty.

A recent study investigated how often SDM actually plays a part in a man’s choice to have or not have a PSA test. Pekala, et al. (2024) note SDM “can improve men’s knowledge and reduce decisional conflict” over screening.^[i] That’s all well and good, but the numbers reveal uneven implementation of the Task Force recommendation. The team found that SDM occurs during office visits anywhere from 11-98% of the time. Where the reported statistics were higher, they were from doctors, not patients. It appears that doctors believe they’re offering their patients SDM, but from the patient’s recollection or even objective study observations, it’s not happening. Why the disconnect?

According to the published paper, there are common barriers to SDM, such as limited appointment times, and patient lack of familiarity with general health concepts. The authors suggest that educational decision (e.g., pamphlets, charts, posters, and webpages) “can help physicians to convey health information within a limited time frame and give patients increased autonomy over decision.” However, such items are underused.

Thus, we can’t count on a patient’s access to SDM so he can judge whether he should have an annual screening test. I suggest that leaving it up to SDM is shortsighted, especially if it isn’t even occurring. Instead, I would prefer a rule of thumb whereby men begin PSA testing at recommended age-specific points, taking into account any other risk factors (ethnicity, family history, toxic exposure, etc.) that might require an earlier starting point. This overcomes problems with the Task Force’s advice about SDM before PSA. European studies continue to show that early detection using PSA screening followed by MRI if indicated saves lives. Therefore, I recommend that after the first PSA test, men commit to an annual test, knowing that they have options other than an immediate biopsy. In this model, an abnormal PSA would lead to a repeat blood test in several weeks and then, if still abnormal, a 3T multiparametric MRI to determine if a biopsy is even needed. At least 38% of biopsies can be avoided in this manner.

Based on the Pekala study, I’m concerned that if SDM isn’t being implemented for PSA screening, how do we know if it’s being done once a man is diagnosed with PCa and has to make treatment decisions? In our own experience at the Sperling Prostate Center, we are fortunate that the vast majority of our patients have high “health literacy”. They are aware of men’s health issues, and they have taken time to educate themselves about PCa and treatment options. Intensive SDM occurs as we go over their MRI scans and biopsy results together. Plus, listening to their life and lifestyle concerns helps me suggest ways to personalize their treatment—and ultimately, empower them to make the choice that not only makes the most sense, but the one that intuitively “feels right.” SDM must include not only intellectual judgment, but should address mind and spirit as well as body.

At our Center, we’re all about SDM. Discussion and correct information before action helps us both, doctor and patient, take each man’s unique situation into account. Contact us to learn how we can share decision-making together.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Pekala KR, Shill DK, Austria M, Langford AT et al. Shared decision-making before prostate cancer screening decisions. Nat Rev Urol. 2024 Jan 2. doi: 10.1038/s41585-023-00840-0.