JAMA Internal Medicine: Prostate Cancer Topic Collection

Comparing 3 Techniques for Eliciting Patient Values for Decision Making About Prostate-Specific Antigen Screening A Randomized Controlled Trial Values for Decision Making About PSA Screening

Pignone M, Howard K, Brenner A, et al. — Mon, 11 Mar 2013 00:00:00 GMT

Importance

To make good decisions about prostate-specific antigen (PSA) screening, men must consider how they value the different potential outcomes.

Objective

To determine the effects of different methods of helping men consider such values.

Design and Setting

Randomized trial from October 12 to 27, 2011, in the general community.

Participants

A total of 911 men aged 50 to 70 years from the United States and Australia who had average risk. Participants were drawn from online panels from a survey research firm in each country and were randomized by the survey firm to 1 of 3 values clarification methods: a balance sheet (n = 302), a rating and ranking task (n = 307), or a discrete choice experiment (n = 302).

Intervention

Participants underwent a values clarification task and then chose the most important attribute.

Main Outcome Measures

The main outcome was the difference among groups in the most important attribute. Secondary outcomes were differences in unlabeled test preference and intent to undergo screening with PSA.

Results

The mean age was 59.8 years; most participants were white and more than one-third had graduated from college. More than 40% reported a PSA test within 12 months. The participants who received the rating and ranking task were more likely to report reducing the chance of death from prostate cancer as being most important (54.4%) compared with those who received the balance sheet (35.1%) or the discrete choice experiment (32.5%) (P < .001). Those receiving the balance sheet were more likely (43.7%) to prefer the unlabeled PSA-like option (as opposed to the “no screening”–like option) compared with those who received rating and ranking (34.2%) or the discrete choice experiment (20.2%). However, the proportion who intended to undergo PSA testing was high and did not differ between groups (balance sheet, 77.1%; rating and ranking, 76.8%; and discrete choice experiment, 73.5%; P = .73).

Conclusions and Relevance

Different values clarification methods produce different patterns of attribute importance and different preferences for screening when presented with an unlabeled choice. Further studies with more distal outcome measures are needed to determine the best method of values clarification, if any, for decisions such as whether to undergo screening with PSA.

Trial Registration

clinicaltrials.gov Identifier: NCT01558583

Bridging the Gap at the Center of Patient Centeredness: Individual Patient Preferences in Health Care Decision Making Comment on “Comparing 3 Techniques for Eliciting Patient Values for Decision Making About Prostate-Specific Antigen Screening” Bridging the Gap at Center of Patient Centeredness

Knight SJ. — Mon, 11 Mar 2013 00:00:00 GMT

Patient-centered care has been identified as one of 6 aims to achieving the health care system quality aspired to in the 21st century. It is described as health care that is “respectful and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions.”

In This Issue of JAMA Internal Medicine

Mon, 11 Mar 2013 00:00:00 GMT

Prostate-Specific Antigen for Prostate Cancer Screening: A Different Strategy Should Be Planned

Lippi G, Mattiuzzi C, Cervellin G. — Mon, 11 Mar 2013 00:00:00 GMT

We read with interest the Research Letter by Howard about declines in prostate cancer incidence among men 75 years and older after changes in screening recommendations. Along with the valuable comments of Katz, who clearly emphasized that the harms of screening may largely outweigh the benefits in younger men as well, it is now undeniable that a rather different screening strategy should be planned, based on the use of more specific and clinically useful biomarkers. The leading drawbacks of total prostate-specific antigen (PSA) testing are indeed represented by overdiagnosis and inability to reliably differentiate indolent from aggressive cancers. However, there is now solid evidence that the Prostate Health Index (PHI) has a diagnostic specificity that is 2- to 4-fold higher than total PSA at identical sensitivity thresholds. A significant relationship between Gleason score and PHI was also found in men with total PSA between 2 and 10 ng/mL (to convert to micrograms per liter, multiply by 1), which is thereby crucial for identifying those men harboring more clinically relevant prostate cancers and increased likelihood of death. Even more interestingly, a strategy entailing the combination of total PSA and PHI was also proven to be less expensive than a PSA-only strategy, with gains of up to 0.08 in quality-adjusted life years.

Prostate Cancer Screening and Incidence: A Question of Causality

Sammon J, Sukumar S, Trinh Q. — Mon, 11 Mar 2013 00:00:00 GMT

In the Research Letter titled “Declines in Prostate Cancer Incidence After Changes in Screening Recommendations,” Howard demonstrates an immediate decline in the incidence of early-stage prostate cancer among men 75 years or older, following the US Preventive Services Task Force (USPSTF) recommendations against screening men in this age group. This finding is of particular interest given recent data that demonstrate stable rates of self-reported screening in men 75 years or older between 2005 and 2010. There is face validity to Howard's assertion, and the temporality of screening recommendations and incidence merits further investigation; nonetheless, the implicit limitations of observational data caution against apportionment of causality. Observational data often demonstrate the influence of secular trends that require complex statistical methodology to control for measured and unmeasured confounding.

Prostate Cancer Screening and Incidence: A Question of Causality—Reply

Howard DH. — Mon, 11 Mar 2013 00:00:00 GMT

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