- Email: [email protected]
Giving patients balanced information about prostate cancer screening reduces their interest in being screened
Evidence-based patient choice
® Pearson
Giving patients balanced information about prostate cancer screening reduces their interest in being screened
Wolf A M. Impact of i n formed consent on patient htterest in prostate-specific antigen. Arch Intern Med 1996; 156:1333-1336
Objective To determine whether scripted patient information about prostate-specific antigen (PSA) screening would influence men's decision to be screened for cancer of the prostate.
dying from prostate cancer, of PSA screening detecting the cancer, of how a positive test would be evaluated, as well as the main options for management of prostate cancer, and discouraging men over 75 to take the test.
Setting
Main outcome measures
Four university-affiliatedprimary care practices in the USA.
1. Interest in PSA screening, measured on a five-point Likert scale 2. Socio-demographic variables: age; race; education; income; health insurance status; family history of prostate cancer and other cancers; self-perceived health status; self-reported prior exposure to information about PSA screening and prostate cancer.
Method A randomized controlled trial. Literature search strategy None stated; 16 references.
Main results
Subjects 205 English-speaking men, 50 years or older, the majority of whom earned less than $15 000 and who did not finish high school, attending primary care physicians for outpatient appointments. Exclusion criteria included having been previously screened for PSA or having a history of prostate cancer. Intervention Participants were randomly allocated to a treatment group ( n - 103), who were read a script of information about PSA screening by a trained research assistant, and a control group (n = !02) who were read a brief statement about PSA screening being a way to detect prostate cancer. The educational script (available in the article) included information about the chance of getting and
Level of interest in screening was most strongly predicted by whether or not the participant had been exposed to the educational intervention,with those exposed having a significantlydecreased interest (odds ratio 0.32, 95% confidence intervals 0.19-0.54, P < 0.001). Advancing age was also inversely related to interest in screening (OR 0.97 per year of age, 95% CI 0.94-1.00, P = 0.04), while a family history of prostate cancer was significantly associated with interest in screening (OR 3.95, 95% CI 1.52-10.29, P = 0.005). No other variables predicted interest in screening. Authors' conclusions Providing patients with balanced information about PSA screening is likely to decrease their interest in it.
Professional Ltd 1997
Commentary This study demonstrates that providing certain information about PSA screening is associated with a reduced interest in screening. This is inconsistent with other research in the area of resuscitation which shows that patients provided with information about the effectiveness of cardiopulmonary resuscitation have a lower interest in being resuscitated. ~-~One conclusion to draw is that patients have inflated expectations of the usefulness of some forms of medical treatment, screening and testing, and when properly informed of their risks and benefits, have a lower interest in receiving those interventions. Interestingly, involving patients in advance planning about the end of life has not been shown to reduce resource consumption,6,7 though the magnitude of cost savings in the presence of properly provided information is not clear. Patients at any rate appear to value such discussions,s-t° The authors are right to claim that giving information is an intervention. This study also illustrates the problems of providing information in an unbiased, nondirective way. Reduction of interest in PSA testing may have been a function of positive framing~l,~2around the consequences of not screening. For example, the patient information sheet stated that 'prostate cancer often does not cause any problem' and that 'many doctors will recommend no treatment for older men who aren't bothered by their cancer'. Patients were not provided with information on the false-negative rate. People are loss-averse. 13Loss-averse people may well want to know the false-negative rate of a test because if the test has a very low false-negative rate, those most concerned with excluding a diagnosis of prostatic cancer may well be interested in the test. The patient information sheet also states that the average 50-year-old man is more likely to die from other forms of cancer, which is against the flavor of the claim in the opening paragraph in the body of the article that prostatic cancer is the second leading cause of cancer death. Why do patients receive different information from clinicians? Information can be used to facilitate autonomy, to enable choice and help patients decide which treatment is best for them; it can also be used to frustrate autonomy, to direct preference and to engineer choice in an attempt to decrease interest in medical care and save money. Dr Julian Savulescu Clinical Ethicist Oxford University, UK
48
EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT
JUNE t997
Givingpatients balancedinformationaboutprostate cancerscreening ] Ret'crences 1. Miller D L, Jahnlgen D W, Gorbien M J, Simbartl L. Cardiopulmonary resuscitation: how use ful? Attitudes and knowledge of an elderly population. Arch Intern/',led 1992; 152:578-582 2. Murphy D J, Burrow D, Santilli S el al. The influence of probabilities on survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Mc'd 1994; 330:545-549 3. Schon~elter R S, Teasdale T A, Taffet G, Robertson B E, Luehl R J. Educating the elderly: cardiopulmonary resuscitation decisions before and after an intervention. J Am Geriatr Soe 1991; 39:372-377 4. Walker R Mj Sehomvetter R S, Kramer D R, Robertson B E. Living wills and resuscitation preferences ia an elderly population_ Arch Imern
J U N E 1997
Med 1995; 155:171-175 5- Godktn/~ I D, Toth E L. CardlopuImonary resuscilalion and older adults expectations. Gerontologist 1994; 34:797-802 6. Schnelderman L J, Kronlek R, Kuplan R M, Anderson J P, Langer R D. Effect of offering advance directives on medical treatments and costs. Ann Intern Med 1992; 117:5599-5606 7. Teno J M, Lynn J, Phillips R Set al. Do formal advance directives affect resuscitation decisions and the use of resources for seriously ill patients? l Clia Ethics 1994; 5:23-30 8. Smucker W D, Ditto P It, Moore K Aet al. Elderly outpatients respond favourably to a physician-initlatedadvance directive discussion. 1 Am Board Fam Pract 1993; 6:473--482 9. Sitvers~elrt M D,S~ockingCB, A n l e l J P,
EVIDENCE-BASED
10.
11.
12.
13.
Becksvlth J, Roos R P, Siegler M- Amy~trophi¢ lateral sclerosis and life-susmlnlngtherapy: patJentsf desires for information, parlicipatJon in decision making, and life-sustainlngtherapy. Mayo Clin Proe 1991; 66:90613 Lo B, Mcleod G A, SaJka G. Patient attitudes to lifesustaining treatment. Arch Intern Met t986; 146:1613-1615 Tversky A, Kahneman D. The framing of decisions and the psychology ofcholce. Science 1981; 211 : 453--458 Kahneman D, Slovle P, Tver~ky A, eds. Judgement under uncertainty: heuristics and biases. Cambridge: Cambridge University Press, 1982 Kahneman D, Varey C. Note~ on the psychology of utility. In: Elster J, Roemer J E. eds. Interpersonal comparisons of well-being: 127-163
HEALTH POLICY AND MANAGEMENT
49
® Pearson
Giving patients balanced information about prostate cancer screening reduces their interest in being screened
Wolf A M. Impact of i n formed consent on patient htterest in prostate-specific antigen. Arch Intern Med 1996; 156:1333-1336
Objective To determine whether scripted patient information about prostate-specific antigen (PSA) screening would influence men's decision to be screened for cancer of the prostate.
dying from prostate cancer, of PSA screening detecting the cancer, of how a positive test would be evaluated, as well as the main options for management of prostate cancer, and discouraging men over 75 to take the test.
Setting
Main outcome measures
Four university-affiliatedprimary care practices in the USA.
1. Interest in PSA screening, measured on a five-point Likert scale 2. Socio-demographic variables: age; race; education; income; health insurance status; family history of prostate cancer and other cancers; self-perceived health status; self-reported prior exposure to information about PSA screening and prostate cancer.
Method A randomized controlled trial. Literature search strategy None stated; 16 references.
Main results
Subjects 205 English-speaking men, 50 years or older, the majority of whom earned less than $15 000 and who did not finish high school, attending primary care physicians for outpatient appointments. Exclusion criteria included having been previously screened for PSA or having a history of prostate cancer. Intervention Participants were randomly allocated to a treatment group ( n - 103), who were read a script of information about PSA screening by a trained research assistant, and a control group (n = !02) who were read a brief statement about PSA screening being a way to detect prostate cancer. The educational script (available in the article) included information about the chance of getting and
Level of interest in screening was most strongly predicted by whether or not the participant had been exposed to the educational intervention,with those exposed having a significantlydecreased interest (odds ratio 0.32, 95% confidence intervals 0.19-0.54, P < 0.001). Advancing age was also inversely related to interest in screening (OR 0.97 per year of age, 95% CI 0.94-1.00, P = 0.04), while a family history of prostate cancer was significantly associated with interest in screening (OR 3.95, 95% CI 1.52-10.29, P = 0.005). No other variables predicted interest in screening. Authors' conclusions Providing patients with balanced information about PSA screening is likely to decrease their interest in it.
Professional Ltd 1997
Commentary This study demonstrates that providing certain information about PSA screening is associated with a reduced interest in screening. This is inconsistent with other research in the area of resuscitation which shows that patients provided with information about the effectiveness of cardiopulmonary resuscitation have a lower interest in being resuscitated. ~-~One conclusion to draw is that patients have inflated expectations of the usefulness of some forms of medical treatment, screening and testing, and when properly informed of their risks and benefits, have a lower interest in receiving those interventions. Interestingly, involving patients in advance planning about the end of life has not been shown to reduce resource consumption,6,7 though the magnitude of cost savings in the presence of properly provided information is not clear. Patients at any rate appear to value such discussions,s-t° The authors are right to claim that giving information is an intervention. This study also illustrates the problems of providing information in an unbiased, nondirective way. Reduction of interest in PSA testing may have been a function of positive framing~l,~2around the consequences of not screening. For example, the patient information sheet stated that 'prostate cancer often does not cause any problem' and that 'many doctors will recommend no treatment for older men who aren't bothered by their cancer'. Patients were not provided with information on the false-negative rate. People are loss-averse. 13Loss-averse people may well want to know the false-negative rate of a test because if the test has a very low false-negative rate, those most concerned with excluding a diagnosis of prostatic cancer may well be interested in the test. The patient information sheet also states that the average 50-year-old man is more likely to die from other forms of cancer, which is against the flavor of the claim in the opening paragraph in the body of the article that prostatic cancer is the second leading cause of cancer death. Why do patients receive different information from clinicians? Information can be used to facilitate autonomy, to enable choice and help patients decide which treatment is best for them; it can also be used to frustrate autonomy, to direct preference and to engineer choice in an attempt to decrease interest in medical care and save money. Dr Julian Savulescu Clinical Ethicist Oxford University, UK
48
EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT
JUNE t997
Givingpatients balancedinformationaboutprostate cancerscreening ] Ret'crences 1. Miller D L, Jahnlgen D W, Gorbien M J, Simbartl L. Cardiopulmonary resuscitation: how use ful? Attitudes and knowledge of an elderly population. Arch Intern/',led 1992; 152:578-582 2. Murphy D J, Burrow D, Santilli S el al. The influence of probabilities on survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Mc'd 1994; 330:545-549 3. Schon~elter R S, Teasdale T A, Taffet G, Robertson B E, Luehl R J. Educating the elderly: cardiopulmonary resuscitation decisions before and after an intervention. J Am Geriatr Soe 1991; 39:372-377 4. Walker R Mj Sehomvetter R S, Kramer D R, Robertson B E. Living wills and resuscitation preferences ia an elderly population_ Arch Imern
J U N E 1997
Med 1995; 155:171-175 5- Godktn/~ I D, Toth E L. CardlopuImonary resuscilalion and older adults expectations. Gerontologist 1994; 34:797-802 6. Schnelderman L J, Kronlek R, Kuplan R M, Anderson J P, Langer R D. Effect of offering advance directives on medical treatments and costs. Ann Intern Med 1992; 117:5599-5606 7. Teno J M, Lynn J, Phillips R Set al. Do formal advance directives affect resuscitation decisions and the use of resources for seriously ill patients? l Clia Ethics 1994; 5:23-30 8. Smucker W D, Ditto P It, Moore K Aet al. Elderly outpatients respond favourably to a physician-initlatedadvance directive discussion. 1 Am Board Fam Pract 1993; 6:473--482 9. Sitvers~elrt M D,S~ockingCB, A n l e l J P,
EVIDENCE-BASED
10.
11.
12.
13.
Becksvlth J, Roos R P, Siegler M- Amy~trophi¢ lateral sclerosis and life-susmlnlngtherapy: patJentsf desires for information, parlicipatJon in decision making, and life-sustainlngtherapy. Mayo Clin Proe 1991; 66:90613 Lo B, Mcleod G A, SaJka G. Patient attitudes to lifesustaining treatment. Arch Intern Met t986; 146:1613-1615 Tversky A, Kahneman D. The framing of decisions and the psychology ofcholce. Science 1981; 211 : 453--458 Kahneman D, Slovle P, Tver~ky A, eds. Judgement under uncertainty: heuristics and biases. Cambridge: Cambridge University Press, 1982 Kahneman D, Varey C. Note~ on the psychology of utility. In: Elster J, Roemer J E. eds. Interpersonal comparisons of well-being: 127-163
HEALTH POLICY AND MANAGEMENT
49