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“What should happen before asymptomatic men decide whether or not to have a PSA test?” A report on three community juries

Chris Degeling, Lucie Rychetnik, Kristen Pickles, Rae Thomas, Jennifer A Doust, Robert A Gardiner, Paul Glasziou, Ainsley J Newson and Stacy M Carter
Med J Aust 2015; 203 (8): 335. || doi: 10.5694/mja15.00164

Summary

Objectives: To elicit the views of well informed community members on the ethical obligations of general practitioners regarding prostate-specific antigen (PSA) testing, and what should be required before a man undergoes a PSA test.

Design and setting: Three community juries held at the University of Sydney over 6 months in 2014.

Participants: Forty participants from New South Wales, of diverse social and cultural backgrounds and with no experience of prostate cancer, recruited through public advertising: two juries of mixed gender and ages; one all-male jury of PSA screening age.

Results: In contrast to Royal Australian College of General Practitioners guidelines, the three juries concluded that GPs should initiate discussions about PSA testing with asymptomatic men over 50 years of age. The mixed juries voted for GPs offering detailed information about all potential consequent benefits and harms before PSA testing, and favoured a cooling-off period before undertaking the test. The all-male jury recommended a staggered approach to providing information. They recommended that written information be available to those who wanted it, but eight of the 12 jurors thought that doctors should discuss the benefits and harms of biopsy and treatment only after a man had received an elevated PSA test result.

Conclusions: Informed jury participants preferred that GPs actively supported individual men in making decisions about PSA testing, and that they allowed a cooling-off period before testing. However, men of screening age argued that uncertain and detailed information should be communicated only after receiving an elevated PSA test result.

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  • Chris Degeling1
  • Lucie Rychetnik2
  • Kristen Pickles1
  • Rae Thomas3
  • Jennifer A Doust3
  • Robert A Gardiner4
  • Paul Glasziou3
  • Ainsley J Newson1
  • Stacy M Carter1

  • 1 University of Sydney, Sydney, NSW
  • 2 University of Notre Dame, Sydney, NSW
  • 3 Bond University, Gold Coast, QLD
  • 4 The University of Queensland Centre for Clinical Research, Redland City, QLD


Acknowledgements: 

Chris Degeling, Kristin Pickles, Lucie Rychetnik and Stacy Carter received funding from NHMRC project grant #1023197. Stacy Carter is also supported by an NHMRC Career Development Fellowship (#1032963) and Paul Glasziou by an NHMRC Australia Fellowship (#0527500). Rae Thomas, Jennifer Doust and Paul Glasziou received funding from Bond University and NHMRC program grant #633033.

Competing interests:

No relevant disclosures.

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access_time 10:37, 27 October 2015
Shomik Sengupta

We commend the authors for this interesting study, which shows that informed members of the community prefer that general practitioners (GPs) offer prostate-specific antigen (PSA) testing for the early diagnosis of prostate cancer with discussion of potential benefits and harms. The widespread uptake of PSA-testing in Australia reflects this, but recently released data1 from the Victorian Cancer Registry shows a reduction in testing, which may lead to significant cancers being missed until too late.

Decision-making on PSA-testing, already difficult for GPs and their patients given the nuances inherent in considering risks and benefits, has been further exacerbated by conflicting recommendations from expert groups. In particular, the Royal Australian College of General Practitioners recommendation to not raise the issue of PSA-testing runs counter to established practice for many GPs and the findings from this study. The medico-legal consequences of following this recommendation or otherwise remain unclear.2 We welcome the consensus guidelines3 (currently in draft form) developed under leadership of the Prostate Cancer Foundation of Australia and Cancer Council Australia and contributed to by the Urological Society of Australia and New Zealand, which will hopefully provide clarity.

1. Cancer Council Victoria. Cancer in Victoria – Statistics and Trends 2014. Melbourne: Cancer Council Victoria, 2015. http://www.cancervic.org.au/downloads/cec/cancer-in-vic/CCV-statistics-trends-2014.pdf, (accessed 26 Oct 2015).
2. Mahar P, Corcoran N, Ludlow K and Sengupta S. Prostate specific antigen: useful screening tool or potential liability? Aust Fam Physician, 2010; 39: 598-600.
3. Prostate Cancer Foundation of Australia and Cancer Council Australia; PSA Testing Guidelines Expert Advisory Panel. Draft clinical practice guidelines PSA testing and early management of test-detected prostate cancer. Sydney: Cancer Council Australia, 2014. http://wiki.cancer.org.au/aus

Competing Interests: USANZ represents urologists, who treat men with prostate cancer

Assoc Prof Shomik Sengupta
USANZ - Oncology advisory group leader

access_time 08:20, 2 November 2015
Chris Degeling

While we agree with Mr Sengupta and Professor Frydenberg that decision-making on PSA-testing is difficult for GPs and their patients, we have concerns that their comments miss several important distinctions. A majority of participants in the three juries thought that GPs should raise the issue of PSA testing with asymptomatic men. However the underlying rationale for this position was not whether to offer PSA testing but about concerns regarding equality of opportunity. Participants wanted to make sure that men did not get conflicting or arbitrary information from non-authoritative or untrustworthy sources. Their key concern was that all men are given the opportunity to find out about the potential benefits and risks of screening for this disease: it was not to promote PSA screening.

This leads to our second concern that intentionally or otherwise, Mr Sengupta and Professor Frydenberg appear to conflate offering the PSA test with providing information. Most jurors wanted men to be informed (or at least offered the opportunity to be informed) well before being offered the test – with many going so far as to strongly endorse that a ‘cooling off’ period should be inserted between these two steps. While these differences in ordering and prioritizing information provision and PSA testing may seem to be minor or mere semantics, their implications are not. It was clear that jurors did not want men to be offered the test with the option of also receiving some information. They wanted GPs to use their expertise and work with men to promote decisions that best reflect the situation, priorities and values of individual patients, and intended that men may or may not decide to proceed to testing, depending on these factors.

Competing Interests: No relevant disclosures

Dr Chris Degeling
University of Sydney

access_time 02:11, 5 November 2015
Shomik Sengupta

We thank the authors for their response however they have misinterpreted our comments entirely as we have not asked for more testing, nor screening.

We simply wished to stress that the at risk men, many of whom wouldn't even be aware of prostate cancer risks, shouldn't be in a position that they have to research about the risks and benefits about PSA based testing from outside sources themselves, knowing as we do that much of that information is factually incorrect. It also assumes a level of medical literacy and knowledge in the community that many do not possess and this leads to inequitable care.

Our position is that GPs should discuss the test with the patients of appropriate age and health pro-actively, and not wait to be asked (the current recommendation of the RACGP). The risks and benefits of PSA based testing need discussion with their GP and we have no concerns about that process nor cooling off periods and did not suggest otherwise. We again commend the authors on this important work and do not feel that our position differs in any way from theirs.

Competing Interests: USANZ represents urologists, who treat men with prostate cancer

Assoc Prof Shomik Sengupta
USANZ - Oncology advisory group leader

Responses are now closed for this article.