To screen or not to screen, when clinical guidelines disagree: primary care physicians' use of the PSA test

Preventive Medicine 38 (2004) 182 – 191 www.elsevier.com/locate/ypmed

To screen or not to screen, when clinical guidelines disagree: primary care physicians’ use of the PSA test Crystale Purvis Cooper, Ph.D., a,* Tracie L. Merritt, M.S.P.H., a Louie E. Ross, Ph.D., a Lisa V. John, M.S.W., b and Cynthia M. Jorgensen, Dr.P.H., a a

National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA b Battelle Centers for Public Health Research and Evaluation, St. Louis, MO 63141, USA

Abstract Background. Clinical guidelines for using the prostate-specific antigen (PSA) test as a population-based screening tool vary considerably. This study qualitatively explored primary care physicians’ PSA screening practices and their understanding of the PSA screening controversy. Methods. Fourteen telephone focus groups were conducted with 75 primary care physicians practicing in 35 US states. Data were coded around three major topics: PSA screening practices, factors influencing these practices, and familiarity with clinical guidelines. Results. Two practice patterns emerged. Most participants recommended regular PSA screening beginning around age 50 for asymptomatic men with no known risk factors and at least a 10-year life expectancy. These ‘‘routine screeners’’ attributed their approach to experience that supported the benefit of PSA screening and to patient demand for the test. Other physicians discussed the implications of PSA screening with patients before offering the test, but neither recommended for or against it. The approach of these ‘‘nonroutine screeners’’ was primarily guided by the lack of scientific evidence documenting the benefit of PSA screening. Conclusions. The observed practice patterns reflect both sides of the PSA screening controversy. While routine and nonroutine screeners differ in their approach, both reported high rates of PSA screening. Published by The Institute For Cancer Prevention and Elsevier Inc. Keywords: Prostatic neoplasms; Mass screening; Prostate-specific antigen; Primary health care; Physicians; Physician’s practice patterns; United States

Introduction The prostate-specific antigen (PSA) test is widely used to screen men for prostate cancer in primary care settings [1– 15], yet its effectiveness as a population-based screening tool has not been proven [16]. Ongoing clinical trials investigating whether PSA screening decreases overall mortality and morbidity will not generate results for several years [17]. Meanwhile, the clinical guidelines for using the PSA test as a population-based screening tool vary among organizations (Table 1). Despite this lack of consensus, primary care physicians report that clinical guidelines influence their PSA screening practices [1,6,10,15], and longitudinal

* Corresponding author. Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS K-55, Atlanta, GA 30341. Fax: +1-770488-4639. E-mail address: [email protected] (C. Purvis Cooper).

reviews of medical records found that primary care physicians’ use of PSA screening increased after the American Cancer Society endorsed routine PSA screening in 1992 [12,15]. However, in the one study that actually assessed physicians’ knowledge of clinical guidelines, most participants did not accurately describe the recommendations of the American Cancer Society and US Preventive Services Task Force [1]. Other practice influences reported by primary care physicians include their beliefs about the effectiveness of PSA screening [1,6,7], patient expectations [1,6], perceived community standards of care [1,6,14], recommendations of urologists [6], and concern about malpractice liability [1,14]. Past studies that assessed the PSA screening practices of primary care physicians have relied on medical record review and closed-ended surveys. In addition, few studies have investigated physicians’ attitudes towards screening and their understanding of PSA screening guidelines. This study qualitatively explored primary care physicians’ PSA screen-

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Table 1 Selected clinical guidelines on PSA screening Organization

Year released/ updated

Guideline statement

American Cancer Society

2001

‘‘The PSA test. . .should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years. Men at high risk should begin testing at age 45. . ..Prior to testing, men should have an opportunity to learn about the benefits and limitations of testing for early prostate cancer detection and treatment’’ [18].

American College of Physicians

1997

‘‘Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient’s concerns; and then individualize the decision to screen’’ [19].

American College of Preventive Medicine

1998

‘‘The American College of Preventive Medicine recommends against routine population screening with. . .[the] PSA. Men age 50 or older with a life expectancy of greater than 10 years should be given information about the potential benefits and harms of screening and limits of current evidence and should be allowed to make their own choice about screening, in consultation with their physician, based on personal preferences’’ [20].

American Urological Association

1999

‘‘The decision to use PSA for the early detection of prostate cancer should be individualized. Patients should be informed of the known risks and the potential benefits. . ..Early detection of prostate cancer should be offered to asymptomatic men 50 years of age or older with an estimated life expectancy of more than 10 years’’ [21].

Canadian Task Force on the Periodic Health Examination

1994

‘‘There is insufficient evidence to include prostate specific antigen (PSA) screening in the periodic health examination of men over 50 years of age. Exclusion is recommended on the basis of low positive predictive value and the known risk of adverse affects associated with therapies of unproven effectiveness’’ [22].

US Preventive Services Task Force

2002

‘‘. . .the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate-specific antigen (PSA) testing. . .’’ [16].

ing practices, the factors influencing these practices, and their familiarity with clinical guidelines on PSA screening.

Methods During December 2001 and January 2002, 14 telephone focus groups were conducted with 75 primary care physicians practicing in 35 US states. Each group included four to eight participants and lasted 1 h. A professional focus group moderator with extensive experience with telephone focus groups facilitated the discussions. The telephone focus group method was selected to assemble physicians from a wide range of practice settings and geographic locations [23], to enhance participant anonymity [24,25], and to increase participation rates [23,26]. Participants This study was limited to physicians who specialized in family medicine, general practice, or internal medicine; practiced medicine full- or part-time; and served a patient population that included men over 40 years old. A random sample of 1,000 potential participants was drawn from the American Medical Association (AMA) Masterfile, an inventory of licensed US physicians. These physicians were sent

enrollment materials via overnight mail. Interested physicians were screened for eligibility and availability. The groups were filled on a rolling basis with six to eight eligible physicians. A total of 187 physicians expressed interest in participating in the study. However, 64 did not satisfy the inclusion criteria, and 29 were not available when groups were scheduled. Of the 94 physicians scheduled to take part in the focus groups, 78 (83%) participated; the other 16 (17%) were not reached at the time of their groups despite multiple attempts to contact them. In addition, three physicians were connected to their groups, but had to be disconnected before discussion began because of technical difficulties. Thus, the study included a total of 75 participants. About half of participants practiced family medicine (51%) with the remainder divided between internal medicine (33%) and general practice (16%) specialties (Table 2). Most participants were male (79%) and white (84%). The ages of participants ranged from 31 to 76 years (mean = 50 years), and the mean year of graduation from medical school was 1979. Nearly two thirds (65%) reported practicing medicine 40 or more hours per week. Participants were spread across the United States: the largest percentage came from the Southern states (31%), and the smallest group coming from the Eastern states (19%). More than 40% of participants practiced in urban areas with populations of 1

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Table 2 Characteristics of participants and the remainder of American Medical Association masterfile sample Participants (n = 75)

Remainder of masterfile sample (n = 925)

Specialty*

Family medicine Internal medicine General practice

51% 33% 16%

47% 45% 8%

Sex

Male

79%

75%

Race

White Asian African American Hispanic

84% 8% 5% 3%

n.a. n.a. n.a. n.a.

Mean age (years)

50

49

Mean year of medical school graduation

1979

1979

Hours per week in practice

40 +

65%

n.a.

Region

East Midwest South West

19% 29% 31% 21%

20% 22% 34% 24%

Population of city where practice is located

< 100,000 100,000 – 999,999 1,000,000 +

27% 32% 41%

21% 34% 45%

n.a. = not available. * v2 = 7.497, df = 2, P = 0.024.

million or more, and 27% worked in rural areas with populations of less than 100,000. T and v2 tests were used to compare the characteristics of participants with those of the remainder of the AMA Masterfile sample from which participants were recruited. The only significant difference found was in the distribution of practice specialties: fewer study participants specialized in internal medicine, and more specialized in family medicine and general practice than did the remainder of the sample (v2 = 7.497, df = 2, P = 0.024). Study protocol The moderator followed a semistructured discussion guide that encompassed three primary research questions: (1) How do primary care physicians use the PSA test as a screening tool? (2) What factors influence their PSA screening practices? (3) Are primary care physicians familiar with the clinical guidelines on PSA screening? The moderator systematically asked all participants to describe their PSA screening practices. Other research questions were investigated through free-flowing discourse in which the moderator frequently summarized

commentary and probed for alternative points of view. To protect their anonymity, participants were encouraged to use only their first names during the discussions. The focus groups were assembled and tape-recorded by a commercial telephone conferencing service. The protocol for this study was reviewed and approved by the institutional review board of the Centers for Disease Control and Prevention. Analysis Verbatim transcripts were compiled for each group and entered into QSR NUD*IST 5, a qualitative analysis computer software. To begin summarizing the data, three reviewers independently read the transcripts and developed coding categories related to each of the stated research questions. Next, these reviewers assessed the differences and similarities of their respective approaches, and integrated them into a single codebook. Then, four research assistants worked with the reviewers to further refine and pilot test the codebook. Using the final codebook, the three reviewers separately analyzed each of the focus group discussions. Two of the reviewers were designated as primary coders; their agreement ranged from 83% to 95% by group (90% overall). When the two primary coders disagreed, the third coder was consulted and a consensus reached. The codebook was organized around three major topics that parallel the stated research questions: PSA screening practices, factors influencing practices, and familiarity with clinical guidelines. PSA screening practices All practice elements related to PSA screening were abstracted, including screening recommendation, prescreening discussion, use of patient education materials, and screening decisions of patients offered the PSA test. Two practice patterns emerged; a profile of each is presented in Results. Factors influencing practices Discussion of the factors influencing participants’ PSA screening practices encompassed nine topics: experience (professional and personal), patient expectations, scientific evidence, perceived community standards of care, clinical guidelines, practice philosophy, concern about malpractice liability, practice mandates, and cost considerations. These nine factors were rated as being ‘‘major’’ (mentioned in many groups), ‘‘moderate’’ (mentioned in some groups), or ‘‘minor’’ (mentioned in few groups). Familiarity with clinical guidelines Comments related to differing PSA screening guidelines were coded as demonstrating awareness of the lack of consensus, or not. In addition, the accuracy of participants’ descriptions of clinical guidelines was assessed.

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Results

Routine screeners

Two distinct patterns of PSA screening were observed. Most physicians recommended regular PSA screening beginning around age 50 to asymptomatic men with no known risk factors and at least a 10-year life expectancy. These ‘‘routine screeners’’ (n = 58) were present in all 14 focus groups. Other physicians did not routinely recommend PSA screening to this population. These ‘‘nonroutine screeners’’ typically discussed the implications of screening with patients before offering the PSA test, but gave no recommendation about whether to screen. Nonroutine screeners (n = 14) were present in 9 of the 14 focus groups. One physician did not fit either practice pattern; he firmly recommended against PSA screening to all his asymptomatic patients. Finally, two participants said very little about their PSA screening practices and could not be classified. This section presents a profile of both routine and nonroutine screeners organized by the three stated research questions. The results are summarized in Table 3.

Nearly half of the routine screeners in the study practiced family medicine (47%) with the remainder divided between internal medicine (34%) and general practice (19%) specialties. Most of the routine screeners were male (83%) and white (85%). The ages of the routine screeners ranged from 32 to 76 years (mean = 51 years), and the mean year of graduation from medical school was 1978. PSA screening practices Screening recommendation. The majority of routine screeners recommended the PSA test to asymptomatic men with no known risk factors beginning at age 50. However, some started regular screening sooner at ages ranging from 35 to 45. When risk factors were present, routine screeners typically recommended PSA screening earlier. Routine screeners reported that they screened men during health maintenance exams as well as other visits

Table 3 Comparison of routine and nonroutine screeners: PSA screening practices, factors influencing practices, and familiarity with clinical guidelines Routine screeners

Nonroutine screeners

All recommended the PSA test

All offered the PSA test without a recommendation for or against screening

Prescreening discussion

Few discussed the implications of PSA screening

Most discussed the implications of PSA screening

Patient education materials

Few used materials; some interested in using materials

Few used materials; most interested in using materials

Reported screening decisions of asymptomatic men over 50 with a 10-year life expectancy and no risk factors

Majority of patients were screened

Majority of patients were screened

Experience—professional and personal experience that supported the benefit of PSA screening Patient expectations to be screened

Scientific evidence—lack of definitive evidence of the benefit of PSA screening

Scientific evidence—studies that supported the benefit of PSA screening Perceived standards of care—belief that PSA screening was the norm in their community Clinical guidelines—favored the American Cancer Society guidelines Practice philosophy—practiced comprehensive medicine Concern about malpractice liability

Experience—professional and personal experience that disputed the benefit of PSA screening Patient expectations to be screened

Mandates from practice settings or payors Cost considerations

Mandates from practice settings or payors Cost considerations

Familiarity with clinical guidelines Awareness of the lack of consensus

Some were aware

All were aware

Accuracy of descriptions

Few were accurate

Most were accurate

PSA screening practices Recommendation to asymptomatic men over 50 with a 10-year life expectancy and no risk factors

Factors influencing practices Major factors

Moderate factors

Minor factors

Clinical guidelines—favored the US Preventive Services Task Force guidelines Practice philosophy—practiced evidence-based medicine

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since ‘‘some patients only present for care when they have an acute problem.’’ In general, routine screeners advocated annual screening, but a few recommended screening every 2 or 3 years. Some routine screeners continued to screen throughout patients’ lives. However, others stopped recommending PSA screening to patients whom they did not feel would benefit from treatment, such as men with less than a 10-year life expectancy. Routine screeners uniformly shared the belief that PSA screening saves lives. Many associated few, if any, negative repercussions with PSA screening and made statements such as, ‘‘It’s a simple blood test that’s fairly inexpensive and fairly innocuous. I don’t see any cons to it.’’ Other routine screeners acknowledged limitations of the PSA test, such as its high false-positive rate and the potential negative outcomes of screening, including repeated biopsies with no cancer ever found. However, these physicians reported that the PSA test was the best screening tool available and that the negative aspects of the test were outweighed by the positive ones. Prescreening discussion. Before administering the test, most routine screeners gave patients little or no information about PSA screening and its implications. Many simply recommended the test without further explanation. Others did not even mention the PSA test by name, securing permission to conduct the test under the umbrella term ‘‘blood work.’’ Some routine screeners commented that severe time constraints imposed by payors limited their interaction with patients. Other routine screeners reported that they avoided in-depth discussion about the implications of PSA screening because it would cause patients ‘‘unnecessary anxiety.’’ One physician likened such a discussion to telling his children there was a possibility that they would be in a car accident every time they left home. Generally, routine screeners reported that they only had an in-depth prescreening discussion with a patient if he declined the test (to persuade the patient to change his mind) or if the patient had less than a 10-year life expectancy (to explain that PSA screening was not recommended because the likelihood that the patient would die from prostate cancer was very remote). Most routine screeners reserved discussions about the implications of screening until after the PSA test and only had this discussion with patients whose PSA levels were elevated: I don’t tell them the whole history of everything because the majority of them are going to have a real nice low PSA. I tell them we need to get a PSA screening test, and we’ll take it from there. If these people come in with one out of the ordinary which is elevated to the extent that I think we need to do something else, and then we’ll go into a conversation. Use of patient education materials. Few routine screeners provided patients with educational materials about prostate

cancer screening. Some said they did not have any materials on this topic but would use them if they did. Other routine screeners said that PSA screening was too complicated a topic to be explained in patient education materials. Some of these physicians were concerned that educational materials would ‘‘needlessly upset patients.’’ A few reported instances in which this had happened: I find the idea appalling, because it always brings up many questions that really don’t pertain, and it just creates patient anxiety. The Harvard Health Letter and the California Health Letter have caused people to come in wanting explanations of all this stuff, some of which is really fairly esoteric. Other routine screeners explained that their patients would not be interested in educational materials on this topic or that there was no need for such materials because their patients readily agreed to be screened. Screening decisions of patients offered the PSA test. All routine screeners said that the vast majority of their patients agreed to undergo PSA screening. Most routine screeners reported that they could not recall a single patient who had refused the test. The reported reasons for patient refusals included payment issues for uninsured patients, concerns about the negative consequences of testing, fear of cancer, and fear of needles. Factors influencing practices Experience that supported the benefit of PSA screening and patient expectations were found to be major factors influencing the PSA screening practices of routine screeners. Moderate factors were scientific evidence, perceived community standards of care, clinical guidelines, practice philosophy, and concern about malpractice liability. Mandates from practice settings or payors and cost considerations were rated as minor factors. Major factors. Experience. Routine screeners reported that their approach to PSA screening was guided in large measure by professional and personal experience. Routine screeners recounted numerous instances in which patients who were not screened died and patients who were screened survived: A physician in town retired, and I naturally inherited a fair number of his patients. Within the first year, three patients died from prostate cancer who had never been screened. That obviously biased me somewhat to being a little more aggressive. Some routine screeners mentioned that they had family members or friends who had died from prostate cancer, and four participants were prostate cancer survivors themselves. Several reported such events had influenced them to become more vigilant PSA screeners.

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Routine screeners also reported negative experiences with PSA screening. Some mentioned patients with elevated PSA scores who underwent repeated biopsies with no cancer ever found. Even so, routine screeners believed the potential benefit of PSA screening exceeded the potential harm. Patient expectations. A number of routine screeners noted the influence of patient expectations on their PSA screening practices. Participants, especially those in urban areas, reported that their patients were aware of the PSA test and were highly motivated to have it. Some patients tracked their PSA results from year to year and discussed them with their friends. A number of participants noted that their male patients were much more interested in prostate cancer screening than colorectal cancer screening. One routine screener characterized the PSA test as one of the top three services that patients requested (the others were cholesterol testing and genetic screening). Some participants noted that patients were requesting to be screened at younger ages, even in their 20s. Another reported trend was patients asking for the PSA test more than once a year. Generally, routine screeners attempted to dissuade asymptomatic men in their 20s and early 30s with no risk factors from being screened and discouraged asymptomatic men of all ages from screening more frequently than once a year. However, if patients persisted in these requests, routine screeners would generally grant them. Some routine screeners attributed patient demand to information about PSA screening disseminated by the news media. Several commented on the heightened awareness generated by the news coverage of public figures who have been treated for prostate cancer, such as Bob Dole, Rudolph Giuliani, Arnold Palmer, and General Norman Schwarzkopf. Physicians also frequently mentioned that the demand for PSA screening emanated from wives, daughters, or other women in patients’ lives: ‘‘Any guy over 50 who is married who comes in for a physical and does not go home with a PSA, is going to be in trouble with his wife.’’ Patient demand for the PSA test was used to justify the omission of a prescreening discussion. Routine screeners reported that their patients were familiar with the PSA test, knew that they wanted it, and rarely had any concerns about having the test. One physician commented, ‘‘Frankly, I’ve had more people question me about cholesterol screening than the PSA.’’ Thus, most routine screeners reported there was no need to spend limited visit time discussing the PSA test. However, patient demand for PSA screening was not universal. Several routine screeners practicing in rural areas and one who served an Asian immigrant population reported that many of their patients showed little interest in PSA screening and had to be persuaded to undergo the test.

influenced by scientific evidence. Several referenced research studies they believed supported their practices: ‘‘According to the specifics in literature, 50% of the newly diagnosed prostate cancers are clinically localized and they’re curable by available treatments.’’ Some routine screeners were also aware of studies that questioned the benefit of PSA screening, but tended to discount these studies based on their clinical experience: ‘‘I happen to disagree strongly with some of the research, and I don’t really have any data, except my own experience.’’ Perceived community standards of care. A number of routine screeners believed that PSA screening was the standard of care in their practice environment: ‘‘In my community, a PSA is like getting a cholesterol [test]; it is given as part of a routine exam on a 50-year-old guy.’’ Similarly, a few routine screeners reported being comfortable with their approach to screening because in the region where they practiced, ‘‘watchful waiting’’ or some other nonsurgical treatment was the typical therapy for asymptomatic prostate cancer. Clinical guidelines. A few routine screeners commented that they screened in part because the American Cancer Society recommended it, but most said that clinical guidelines were not a factor in their screening decisions. Some routine screeners were wary of the PSA screening guidelines published by the American Urological Association because they seemed ‘‘self-serving.’’ Several physicians specifically stated that their practices were based on their clinical experience, not guidelines: ‘‘My guidelines are what I have seen in the 46 years that I have been practicing medicine.’’ Practice philosophy. Practice philosophy also influenced the practices of routine screeners. Some routine screeners articulated credos such as ‘‘a patient is entitled to know what is going on in his body’’ or reported practicing ‘‘comprehensive medicine’’ regardless of the monetary cost. In addition to being offered as a rationale for using the PSA screening in general, these philosophies were also used to justify screening patients with less than a 10-year life expectancy. Concern about malpractice liability. Several routine screeners acknowledged their practices were influenced in part by concern about malpractice liability. Some participants recounted instances in which a physician was held liable for failing to administer the PSA test when prostate cancer was found later: ‘‘In California, a man got a $1.5 million judgment, even though his physician offered him the PSA test three times.’’ A number of these physicians reported that if a patient decided not to have the PSA test, they documented his refusal in great detail: ‘‘If they opt not to, you have to have a record of it. You have to save your ‘you know what,’ and it has to be in black and white.’’

Moderate factors. Scientific evidence. Some routine screeners commented that their PSA screening practices were

Minor factors. Practice mandates. The vast majority of routine screeners said that they were free to set their own

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policy on PSA screening. Most said that payors generally covered PSA screening, but did not mandate that it be done. No routine screeners worked in practice settings with formal PSA screening policies, although some reported having informal discussions with colleagues to gauge the screening practices of others. Cost considerations. Cost considerations had little effect on routine screeners’ PSA screening practices. The cost of the PSA test itself was deemed moderate, and routine screeners recommended it to both insured and uninsured patients. No participants mentioned the potential costs of follow-up testing and treatment. Although cost had little influence on the screening recommendations of routine screeners, it was reported to influence the willingness of uninsured patients to undergo the test. Familiarity with clinical guidelines Awareness of the lack of consensus. A number of routine screeners believed that population-based PSA screening was universally endorsed. Some of these responded incredulously when the debate surrounding PSA screening was discussed by other group members: ‘‘What controversy? There is no controversy.’’ Other routine screeners demonstrated an understanding of the PSA screening controversy: ‘‘The evidence is not clear cut as to whether the PSA saves lives, even though I believe that it does.’’ As reported previously, few routine screeners characterized clinical guidelines as being an important influence on their PSA screening practices. Accuracy of descriptions. Routine screeners were frequently unable to describe the recommendations of any specific organization. When routine screeners provided descriptions, they were often inaccurate. For instance, several routine screeners erroneously reported that the US Preventive Services Task Force recommends regular PSA screening. Nonroutine screeners Of the 14 physicians classified as nonroutine screeners, 71% practiced family medicine and the remainder specialized in internal medicine (29%). Most of the nonroutine screeners were male (64%) and white (79%). The ages of the nonroutine screeners ranged from 31 to 60 years (mean = 46 years), and the mean year of graduation from medical school was 1984. PSA screening practices Screening recommendation. Nonroutine screeners gave no recommendation about PSA screening to asymptomatic men over age 50 with no risk factors and at least a 10-year life expectancy. With this population, they discussed the implications of screening, then offered the PSA test. However, some of these physicians recommended regular PSA screen-

ing for patients at increased risk, such as African American men. Nonroutine screeners typically reserved discussions about PSA screening for health maintenance visits: ‘‘I don’t want to take time away from acute problems.’’ Nonroutine screeners shared the concern that the PSA test may bring patients more harm than benefit. One physician likened the PSA test to Pandora’s box, a mythical box that unleashed unforeseen evil when opened. Prescreening discussion. Several nonroutine screeners spoke passionately about the rights of patients to know the implications of PSA screening before undergoing the test. These participants characterized their prescreening discussion with patients as both complicated and timeconsuming: I wish that I was a strong advocate of PSA screening so that I could just take about 20 seconds and say that I strongly recommend that we add this blood test on and that would be the end of it. But instead, I end up spending probably close to 5 minutes talking about the risks and benefits of PSA screening. Nonroutine screeners reported covering several points before screening. Many explained to their patients that the PSA test did not provide a ‘‘yes – no’’ result and that additional tests would be needed to confirm or negate a cancer diagnosis: I would talk about how sometimes the test comes back normal, and that is certainly reassuring. Sometimes the test comes back very high and that seems to really be a problem that we need to pursue. Where the gray and murky and difficult areas come in is where the PSA is only mildly elevated, like say the 6 to 10 level. Then it is difficult to know whether that is something that is going to be a problem for the patient or not. I would talk to them about how that might involve biopsies and surgery with its attendant risk of incontinence and impotence. Some nonroutine screeners explained to patients that clinical guidelines on PSA screening disagree and that the benefit of PSA screening has not been definitively proven: I mention that there is a difference of opinions amongst the bodies that make guidelines for this, and if an elevated level is more likely to be due to benign disease than cancer. Yet to tell the difference, you may end up needing to have a biopsy. Then if the biopsy shows cancer, the treatment might be worse than the disease. Several of these physicians commented that their patients had deeply ingrained beliefs about the clinical benefit of finding and treating cancer early and had ‘‘a very hard time’’ believing that prostate cancer might be an exception to this rule.

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Some nonroutine screeners admitted limiting prescreening discussion when they needed to maximize the time they devoted to more pressing health concerns: ‘‘If a patient weighs 300 pounds, then I am going to spend most of my discussion time educating them about diet and exercise.’’ Also, a few nonroutine screeners commented that they abbreviated the discussion if a patient had already made up his mind about screening: ‘‘If I start the discussion and they say, ‘I want it for sure,’ then I wouldn’t get into the details.’’ Use of patient education materials. Most nonroutine screeners were very interested in obtaining and using patient education materials about prostate cancer screening. Some already had materials and distributed them to patients; others had searched for materials but were unable to find them. One physician who could not find an existing patient education brochure developed his own. Screening decisions of patients offered the PSA test. Most nonroutine screeners reported that the majority of patients chose to have the PSA test. Although, a few physicians estimated only about half of their patients opted to be screened. After learning the facts about PSA screening, patients refused for a variety of reasons, including the belief that the test may be ‘‘more trouble than it is worth’’ and concern about the potential side effects of treatment. Factors influencing practices Only one major factor influencing the PSA screening practices of nonroutine screeners was identified—scientific evidence. Moderate factors were experience that disputed the benefit of PSA screening, patient expectations, clinical guidelines, and practice philosophy. Mandates from practice settings or payors and cost considerations were minor factors. Nonroutine screeners did not comment on two factors mentioned by routine screeners: perceived community standards of care and concern about malpractice liability. Major factor: scientific evidence. The practices of nonroutine screeners were influenced most by scientific evidence. These physicians frequently mentioned the lack of conclusive research supporting the benefit of PSA screening: Just reading up on it, apparently there’s still no proof that finding it early extends a person’s life, and there’s a lot of morbidity with surgery. There’s no proof that localized cancer will ever spread, and so from what I’ve read it’s just not always indicated. In addition to general references to the literature, nonroutine screeners described some specific studies: There was a study of men who died at the age of 70 with no history of prostate cancer, no evidence of prostate

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cancer. Autopsies were done, and approximately 50% of them did have cancer in their prostate. There is clearly a lot of asymptomatic prostate cancer, and I’m not convinced of our ability to sort that out. Moderate factors. Experience. Professional and personal experience helped shape nonroutine screeners’ approach to PSA screening. A number of these participants reported instances in which a patient with an elevated PSA level underwent repeated biopsies with no cancer ever found. Other nonroutine screeners described negative personal experiences with PSA screening: My own father was diagnosed with prostate cancer via one of those hospital-sponsored urology PSA specials. He went through quite a phase of incontinence, difficulty, and depression, and left us all kind of wondering whether he was really helped in that process. I think that colors my approach to it. Patient expectations. Nonroutine screeners noted the tremendous public demand for the test, and some them commented that ‘‘patients often bring up the PSA test before I have a chance to get to it.’’ Nonroutine screeners attributed this intense interest in part to the news media, and several expressed frustration with unbalanced coverage: ‘‘Most of the media hype about the PSA is about how you can detect cancer. It never presents what the fallacies are.’’ These physicians said that the news coverage of PSA screening reinforced patients’ beliefs about the clinical benefit of finding and treating cancer early. Clinical guidelines. Several nonroutine screeners modeled their screening practices after the recommendations of the US Preventive Services Task Force. These physicians favored this body because the guidelines were based on the scientific evidence. However, other nonroutine screeners commented that guidelines on prostate cancer screening were not useful given the lack of consensus: ‘‘I have seen guidelines to support any position on prostate screening.’’ A number of the participants were suspicious of the American Urological Association guidelines because they seemed to support the financial interest of urologists. Practice philosophy. Practice philosophy also influenced nonroutine screeners’ approach to PSA screening. Some physicians described themselves as practicing evidence-based medicine. Several others emphasized the importance they placed on informed consent: ‘‘I am a strong believer in informed consent. I guess that my feeling about this is that any kind of screening program has costs that go beyond just the dollar cost of it.’’ Minor factors. Practice mandates. Mandates from practice settings or payors and cost considerations had little effect on the practices of nonroutine screeners. Only one nonroutine screener working in a Veterans Administration facility reported that the clinic required physicians to ex-

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plain the pros and cons of PSA screening to patients before offering the test; the clinic’s computer system cued her to have this discussion. No other participants worked in practice settings or were reimbursed by payors that dictated their PSA screening practices. Cost considerations. Cost considerations were rarely mentioned by nonroutine screeners. A few reported that major insurers in their area did not cover PSA screening and that they told patients they may have to pay for the test themselves. One nonroutine screener reported that he did not offer the test to asymptomatic patients without insurance: ‘‘Many of my patients don’t have insurance. There’s no point in ordering something that is of dubious benefit.’’ Familiarity with clinical guidelines Awareness of the lack of consensus. All nonroutine screeners were aware of the lack of consensus among PSA screening guidelines. A typical comment was, ‘‘There’s still a lot of confusion out there in the various guidelines. Very solid sources are saying don’t do regular screening.’’ As discussed previously, some nonroutine screeners even explained the disagreement among guidelines to their patients before offering the PSA test. Accuracy of descriptions. In several instances, a nonroutine screener provided accurate descriptions of the guidelines of three or more organizations. Nonroutine screeners tended to favor the PSA screening guidelines of the US Preventive Services Task Force, but many were familiar with the guidelines of other organizations such as the American Cancer Society, the American College of Physicians, and the American Urological Association.

Discussion The observed practice patterns reflect both sides of the PSA screening controversy: routine screeners encouraged regular PSA screening of asymptomatic men aged 50 years and older, and nonroutine screeners neither recommended nor discouraged PSA screening. Although most clinical guidelines suggest that clinicians discuss the pros and cons of PSA screening before administering the test, only nonroutine screeners tended to follow this recommendation. One of the core differences between routine and nonroutine screeners was the relative value that each group assigned to first-hand experience and scientific evidence. The practices of routine screeners were based in large measure on their professional and personal experience. They recounted numerous instances in which men who were screened lived and men who were not screened died. Conversely, the practices of nonroutine screeners were primarily based on scientific evidence. They tended to justify their approach by referencing research that disputed the benefit of PSA screening.

Although the PSA screening practices of routine and nonroutine screeners differed considerably, the end result of the two practice patterns seems to be similar—both routine and nonroutine screeners reported high screening rates. Nonroutine screeners reported that the prescreening discussion they had with patients rarely dissuaded the patients from having the PSA test. Participants attributed patients’ willingness to undergo screening to favorable news coverage of PSA screening and beliefs about the clinical benefit of finding and treating cancer early. Thus, this study suggests that an in-depth, physician – patient discussion may not significantly influence PSA screening rates. The results of this study are generally consistent with the existing literature. As in past studies [1,6,7], most physicians expressed strong beliefs about the effectiveness of PSA screening. Also, several factors found to influence physician PSA screening practices have been identified by others, including clinical guidelines [1,6,10,15], patient expectations [1,6], perceived community standards of care [1,6,14], and concern about malpractice liability [1,14]. However, important influences not assessed in prior studies were also identified, such as experience and scientific evidence. Like previous research [1], many primary care physicians could not accurately describe the PSA screening guidelines of major medical organizations. However, nonroutine screeners, who constituted the minority of the sample, exhibited a great deal of guideline knowledge. Given the value that nonroutine screeners placed on scientific evidence, it is not surprising they were more aware than routine screeners of the controversy surrounding PSA screening. Researchers further exploring primary care physicians’ use of the PSA test using focus groups should consider conducting separate groups with routine and nonroutine screeners. While it was interesting to observe routine and nonroutine screeners interact, nonroutine screeners represented the minority opinion in almost every group in which they were present. In a few groups, a lone nonroutine screener was paired with three or four routine screeners. These unbalanced group dynamics may have limited the ability or willingness of nonroutine screeners to fully express their opinions. Quantitative research should be conducted to determine the relative frequency of routine and nonroutine patterns of PSA screening. While numerous surveys have investigated the PSA screening practices of primary care physicians, the items used to explore this issue generally did not distinguish between the two practice patterns observed here. For instance, both routine and nonroutine screeners would answer affirmatively to the questions, ‘‘Do you offer PSA screening to asymptomatic men over 50?’’ and ‘‘Are you currently using the PSA test to screen for prostate cancer?’’ Survey research should also explore the physician characteristics associated with routine and nonroutine screening approaches. This formative study suggests that nonroutine screeners are more likely than

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routine screeners to practice family medicine and be more recent medical school graduates. The identified factors influencing screening practices should also be studied quantitatively. In this study, the ranking of these factors was based on their prominence across groups. Future studies should explore whether this hierarchy differs when primary care physicians directly rate the factors.

Acknowledgments The authors thank Shyanika Wijesinha Rose, MA, Keira Armstrong, MPH, Carianne M. Tucker, MPH, CHES, and Aimee Ferraro, MPH, for their assistance with the development of the codebook; Wendy L. Child, MS, for moderating the focus groups; Patrick Kiser for his help coordinating the focus groups; and Ralph J. Coates, PhD, for the guidance that he provided throughout this project. This study was funded by the Centers for Disease Control and Prevention (CDC), and all data analysis was conducted by CDC staff researchers. An abstract describing this study was presented at the 24th Annual Meeting of the Society of Behavioral Medicine held March 19 –22, 2003, in Salt Lake City, Utah.

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