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Prostate Cancer: Educating Men about Informed Decision Making

Prostate Cancer: Educating Men about Informed Decision Making. Kathryn Hess, BS Outreach Specialist Wyoming Comprehensive Cancer Control Program Wyoming Department of Health Preventative Health and Safety Division. Prostate Cancer.

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Prostate Cancer: Educating Men about Informed Decision Making

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  1. Prostate Cancer: Educating Men about Informed Decision Making Kathryn Hess, BS Outreach Specialist Wyoming Comprehensive Cancer Control Program Wyoming Department of Health Preventative Health and Safety Division

  2. Prostate Cancer • Prostate Cancer is the 2nd leading cause of cancer death in American men. • About 1 in 6 men will be diagnosed with Prostate Cancer • Only 1 in every 34 men will die from Prostate Cancer • There are a little over 1.8 million survivors of Prostate cancer in America

  3. Objectives • To discuss what is known about the risk of prostate cancer and its natural history. • To discuss what is known about the potential benefits and potential harms of screening for and treating prostate cancer. • To discuss how primary care clinicians can use shared decision making with their patients in deciding whether to screen for prostate cancer.

  4. Incidence Wyoming

  5. Incidence Trends Wyoming

  6. Incidence and Mortality Summary Wyoming 2004

  7. Overall Risk Center for Disease Control - http://www.cdc.gov/cancer/prostate/prospdf/prosguide.pdf National Data – 2004

  8. Natural History • Prostate cancer is biologically heterogeneous. • Some prostate cancers grow slowly and never cause symptoms. • Other prostate cancers are fast growing and metastasize quickly. • Other types grow at a modest pace.

  9. Prevention • Known risk factors for developing prostate cancer: • Age • Race/ethnicity • Family history of prostate cancer • No agreement on modifiable risk factors

  10. Screening for Prostate Cancer: What is the Big Deal?

  11. Screening Tools Prostate Specific Antigen (PSA) Digital Rectal Exam (DRE)

  12. What are the Issues? • Does screening extend men’s lives (are there potential benefits)? • Does screening cause adverse health issues (are there potential harms)? • Do the benefits outweigh the harms?

  13. Current Screening Guidelines • USPSTF: “the evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA or DRE” • Although screening can find cancer early, it is uncertain whether the potential benefits justify the potential harms • Inconclusive evidence that early detection decreases mortality

  14. Benefits of Screening • PSA screening detects cancers earlier. • Treating PSA-detected cancers may be effective but we are uncertain. • PSA may contribute to the declining death rate but we are uncertain.

  15. Harms of Screening Three issues to consider: • False-positive screening tests. • Overdiagnosis (men who do not benefit from diagnosis). • Side effects of treatment.

  16. False Positives of PSA Screening http://www.health.gov.on.ca/english/providers/pub/cancer/psa/psa_guide/psa.gif

  17. Overdiagnosis • Overdiagnosis is difficult to quantify. • One recent report estimated that during 1988–1998 about 3 of every 10 men aged 60–84 diagnosed with prostate cancer by PSA testing would never have had clinical disease. • Other studies show even higher percentages of overdiagnosis.

  18. Side Effects of Treatment

  19. To Screen OR Not Screen?

  20. Informed Decision Making “An intervention in the clinical setting in which patients and providers collaborate in decision making.” - American Journal of Preventative Medicine

  21. Informed Decision Making Informed decision making means: • Encouraging a patient to participate in the decision. • Helping a patient consider how the evidence fits his values and preferences.

  22. What Should the Patient Know? Do I know the likelihood of various outcomes? Do I understand the benefits? Do I know the potential consequences of my decisions? Do I understand the potential harms?

  23. Benefits of Informed Decision Making How the patient benefits: • Takes an active role in his health care. • Becomes better informed. • Chooses the option most consistent with his personal preferences. How the clinician benefits: • Solves a clinical dilemma. • Informs and involves a patient in his care.

  24. How to use Informed Decision Making These are the key elements: • Provide information: Use decision aids. • Discuss his questions and concerns. • Discuss why men choose different options. • Listen and make a joint decision.

  25. 1. Inform Your Patient • Let him know that the decision is his, with the clinician’s help. • Give him information about: • Prostate cancer. • Screening tests. • Benefits and side effects of treatment .

  26. How Can We Inform Patients? Decision aids: • Are available in different types: Pamphlets, videos, Web-based formats. • Can help achieve different goals: • All inform and promote patient involvement. • Some help patients see that their preferences fit one option better than another. • Can be used at different times: Before, during, or after the visit. • Are available at www.cdc.gov/cancer/prostate

  27. Why use Decision Aids? Evidence suggests such aids help men: • Become better informed. • Understand their options. • Understand which option best fits their preferences.

  28. 2. Discuss His Questions and Concerns • Address misconceptions. • Give him time to think. • Use more than one visit, if needed.

  29. 3. Discuss Why Men Choose Different Options • Patient who decided to be screened: “The way I see it, it’s the best thing we’ve got to protect ourselves from prostate cancer. Even if it saves one life, it is worth all of the possible side effects of treatment. I’m one of those people who just likes to know.” • Patient who chose not to be screened: “The problem is we really don’t know if it will help anyone, and it could hurt people. I think I’ll wait until we know more.”

  30. 4. Listen and Make a Joint Decision • If he is ready to choose, accept and support his decision. • If he is not ready, put the decision off until the next visit. • If he asks what you would choose, tell him you know men who have chosen both options. • If he is unable or does not want to make a decision, give him your recommendation.

  31. Summary • Shared decision making is the best current answer because: • There is evidence that screening may extend men’s lives, but the evidence is not conclusive. • Some men suffer harms from screening. • How men weigh potential harms and benefits depends on the individual. • Our challenge: • To find ways to help men make their own decisions.

  32. Resources USPSTF USPSTF. Screening for Prostate Ca: Recommendations and Rationale. AAFP 2003;4: 787-92 Center for Disease Control http://www.cdc.gov/cancer/prostate/ Wyoming Cancer Surveillance Program Wyoming Department of Health National Cancer Institute www.nci.nih.gov American Cancer Society www.cancer.org

  33. Questions? Kathryn Hess, BS Outreach Specialist, Wyoming Comprehensive Cancer Control Program Khess@state.wy.us 307.777.1918

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