NEWS

Shared Decision-Making Still Evolving in Cancer Screening

Steve Benowitz

A recent survey of primary care physicians showed that doctors often decide whether or not to order screening tests for cancer without talking it over with the patient, a finding that is somewhat unsettling but not entirely surprising.

In the survey, Andrew Dunn, M.D., assistant professor of internal medicine at Mt. Sinai School of Medicine in New York, and his co-workers asked attending physicians and house staff practicing primary care at three New York hospitals about the likelihood of discussing two controversial screening tests—screening mammography and prostate-specific antigen (PSA) testing—with three hypothetical patients without symptoms. The mammogram was for a 45-year-old woman and a 55-year-old woman, respectively, while the PSA testing was for a 55-year-old man.



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Dr. Andrew Dunn

 
Reporting in February in the American Journal of Preventive Medicine, Dunn and his group found that one-third of house staff, attending physicians, and residents said they would not talk about the option of screening mammography or PSA testing with their patients. Only 18% of the doctors surveyed said whether they ordered the test depended on the patient preference. In general, doctors who tended not to order a test also did not plan to discuss that decision with the patient.

One-third to one-half of doctors surveyed said lack of time and complexity of the issue surrounding the screening exam were the main reasons they would not discuss screening options with patients.

To many, the results are hardly surprising.

"The concept of shared decision-making in preventive cancer care is relatively new," said Richard Wender, M.D., clinical professor of family medicine at Jefferson Medical College of Thomas Jefferson University in Philadelphia. "It’s only recently that guidelines for cancer screening have included language that says to engage a shared decision-making model."

That’s particularly true of prostate cancer. According to Wender, who helped draft the American Cancer Society Guidelines for the Early Detection of Cancer and is a member of the ACS Prostate Cancer Advisory Committee, the current guidelines for PSA testing recommend that both doctor and patient discuss the test. In fact, nearly every national medical and patient organization recommends patient involvement in the process, whether or not the group actually supports a particular screening method.

But PSA is controversial. Many call into question the value of regular PSA screening for those without symptoms. For those diagnosed with prostate cancer, the treatment might not affect how long a patient lives, while raising the risk of incontinence and impotence. "It’s a complex interaction of a lack of knowledge of what the state of the evidence is supporting PSA screening and a lack of knowledge as to how to communicate risks of screening" that can hinder a doctor from discussing the matter with the patient, Wender said.

Each cancer brings its own set of complicated issues. "You can’t lump together the effectiveness of cancer screening programs," said Robert Kurtz, M.D., chief of gastroenterology at Memorial Sloan-Kettering Cancer Center in New York. Take colon cancer, for example. "I think some of the confusion for the primary care physician is based on the different approaches to colon cancer screening—fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or barium enema. We need to continue to educate both the patients and physicians."

In the case of breast cancer, the evidence of the value of mammography screening for women in their forties is substantial, if not conclusive, Wender said. "The national debate of whether or not to screen has been basically decided."

Some see shared decision-making as a growing necessity. "Telling a patient what to do just doesn’t work anymore," said Andrew Wolf, M.D., associate professor of medicine at the University of Virginia School of Medicine in Charlottesville. "It particularly doesn’t work in the area of cancer screening, where there is so much uncertainty in the accuracy of the test, the efficacy of treatment, and the risk of adverse effects that may affect the quality of life. Patients must be allowed to apply their own value system to a decision."



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Dr. Andrew Wolf

 
The Mt. Sinai study is limited, Wender noted, and does not necessarily mirror the real world. As many as 80% to 90% of community physicians would likely order a PSA, for example, and most would not consult the patient.

But when a patient wants no part in the decision, many guidelines say as long as the doctor informs the patient about options, the physician can choose, Wender said. "Screening can be a medically complex decision and doctors may have trouble communicating it. Many patients may not fully understand that decision and turn to the doctor."

Many Barriers

Some say better physician training and incentives to discuss prevention with patients are needed. Harried primary care physicians may not have the time or resources.

"Primary care doctors are under tremendous pressure to see patients in a hurry—their income is dependent on it," said Halsted Holman, M.D., co-chief of the division of community and family medicine at Stanford University School of Medicine. "They have to consider if a screening test will give actionable information or merely create apprehension."

"Shared decision-making is a new concept poorly role-modeled in medical schools and in practice," said Lawrence Wu, M.D., assistant professor of family medicine at Duke University Medical Center in Durham. "Health providers’ lack of time, knowledge, and ability to truly engage in a very complex decision-making process. That’s the frontier and to include these discussions routinely will be difficult because they are time-consuming."

The doctor might spend the majority if not all of the visit on the acute illness and not have time to address the need for preventative screenings, he said. At the end of a visit, "the primary care doctor may say, ‘By the way, have you considered PSA, colon cancer screening,’ and if the patient is a woman, a Pap smear and mammography? That’s not shared decision-making."

Reimbursement

Wu, who is director of the Duke University Family Medicine Clinic, sees a problem in the reimbursement structure in preventive medicine. "Our current reimbursement systems do not pay physicians to do this kind of work," he said. "Medicare, for example, doesn’t cover professional fees for preventive counseling.

"If society decides that some of these tests that are controversial are necessary and provide benefit, then it should pay for providers’ time for consultation. Once that’s done, other things will fall in line. Medical schools will emphasize it and doctors will see the financial benefit and it will become more widespread and part of our culture."

What needs to be done? Wender and others stress the need for better educational tools—printed materials, videos, and various computer decision-making aids for patients. "We are in the midst of a paradigm shift in cancer screening and decision-sharing, and it takes a long time," Wolf said.



             
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