Barak Gaster, MD; Kelly Edwards, PhD; Susan Brown Trinidad, MA; Thomas H. Gallagher, MD; Clarence H. Braddock, MD, MPH
Acknowledgment: The authors thank Elizabeth Hopley, Sylvia Bereknyei, Peggy Hannon, and Centers for Disease Control and Prevention (CDC) project officer Donald Blackman for their useful guidance and assistance during the development of this paper.
Grant Support: In part by the CDC and the National Cancer Institute through the Cancer Prevention and Control Research Network, a network within the CDC's Prevention Research Centers Program (grant 1-U48-DP-000050).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1034.
Requests for Single Reprints: Barak Gaster, MD, General Internal Medicine, University of Washington, 4245 Roosevelt Way NE, Seattle, WA 98105; e-mail, email@example.com.
Current Author Addresses: Dr. Gaster: General Internal Medicine, University of Washington, 4245 Roosevelt Way NE, Seattle, WA 98105.
Dr. Edwards and Ms. Trinidad: University of Washington, Health Sciences Building, Room A204, Department of Bioethics and Humanities, Box 357120, Seattle, WA 98195-7120.
Dr. Gallagher: General Internal Medicine, University of Washington, 4311 11th Avenue NE, Suite 230, Seattle, WA 98105.
Dr. Braddock: Stanford School of Medicine, 251 Campus Drive, Medical School Office Building X333, Mail Code 5404, Stanford, CA 94305-5404.
Author Contributions: Conception and design: B. Gaster, K. Edwards, S.B. Trinidad, T.H. Gallagher, C.H. Braddock.
Analysis and interpretation of the data: B. Gaster, K. Edwards, S.B. Trinidad, T.H. Gallagher, C.H. Braddock.
Drafting of the article: B. Gaster, K. Edwards, S.B. Trinidad, T.H. Gallagher, C.H. Braddock.
Critical revision of the article for important intellectual content: B. Gaster, K. Edwards, S.B. Trinidad, T.H. Gallagher, C.H. Braddock.
Final approval of the article: B. Gaster, K. Edwards, S.B. Trinidad, T.H. Gallagher, C.H. Braddock.
Obtaining of funding: K. Edwards.
Administrative, technical, or logistic support: S.B. Trinidad.
Collection and assembly of data: S.B. Trinidad, T.H. Gallagher, C.H. Braddock.
Gaster B., Edwards K., Trinidad S., Gallagher T., Braddock C.; Patient-Centered Discussions About Prostate Cancer Screening: A Real-World Approach. Ann Intern Med. 2010;153:661-665. doi: 10.7326/0003-4819-153-10-201011160-00010
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Published: Ann Intern Med. 2010;153(10):661-665.
National guidelines recommend that primary care providers discuss the risks and benefits of prostate cancer screening with their patients but give little guidance on how to fit such a complex discussion into a busy clinic encounter. The authors propose a process-oriented approach (Ask-Tell-Ask) that promotes tailored conversations and value-based recommendations. The Ask-Tell-Ask approach includes diagnosing a patient's informational needs, providing targeted education based on those needs, and making a shared decision about testing. This time-efficient model emphasizes the provider's role as an interactive guide rather than a one-way supplier of information. Although there is no way to make these discussions simple, this streamlined strategy can help patients and providers efficiently negotiate the complex and important decision of screening for prostate cancer.
November 30, 2010
Cancer screening: Information or promotion?
Gaster et al must be congratulated for providing a tool to efficiently negotiate a complex and important decision: screening or not for prostate cancer.(1) Their targeted approach can be applied to other cancers to fulfil one of our major commitments, the shared decision, which is even more demanding in normal subjects that in patients. France has a different approach.
The French Association of Urologists has promoted prostate cancer screening for many years.(2; see Fig1) The High Authority for Heath (Haute Autorit? de Sant?) waited until June 2010 to publish a re-analysis of its 2004 recommendation. The task force was chaired by a specialist of road accidents with the participation of the Association of Urologists but neither the Society for Public Health nor the College of Family Practice were represented.(3) The task force concluded that "Current knowledge do not recommend mass screening for prostate cancer ". This conlusion deliberately ignores that prostate cancer screening is a massive epidemic in France since many years.(2,4) Indeed, no leaflet was provided to inform the subject on the results of recent trials (ERSPC and PLCO) and meta- analysis. French family doctors must rely on the leaflet provided by the National Health Service of the UK which is happily edited in French.(4, see also www.esculape.com/uronephro/prostate_cancer_expertises- LPM2010.html)
In France, even information about harm from breast cancer screening is unlawfull. "The UNCAM (French health insurance fund national assocaition, the mandatory health insurance scheme) published in 2007 a decision in the official gazette of the French Republic: the family doctor "draws the patient's attention to the benefit of screening ... He develops positive information on the screening, which is among the natural acts of simple monitoring, in order to remove the potential reserves of its patients ..."(Arr?t? du 2 mai 2007. Journal Officiel de la R?publique Fran?aise 2007, n?103 (3 May), 7826. available at : http://www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=SANS0752329A).
In 1923, a French novelist, Jules Romains, wrote a comedy: "Knock or the Triumph of Medical Science" in which, thanks to frightening graphs, an inventive village doctor succeeds in turning the robust inhabitants into confirmed hypochondriacs. This comedy was useless. Now, in France, healthy people are converted into patients by over-emphasizing benefits which are based upon false hope and by masking harms, ignoring randomized clinical trials. We must provide explanation and reassurance to promote autonomy, we must not provide capitalistic goods promoted by faith in false hopes.
1 Gaster B, Edwards K, Trinidad SB, Gallagher TH, Braddock CH 3rd. Patient-centered discussions about prostate cancer screening: A real-world approach. Ann Intern Med 2010;153:661-5
2 Braillon A, Dubois G, Zielinski O. Screening for prostate cancer: a public campaign, evidence-based-medicine and conflicting interests. Eur J Public Health 2009;19:222, available at http://eurpub.oxfordjournals.org/content/19/2/222.full
3 Haute Autorit? de Sant?. Rapport d'orientation. D?pistage du cancer de la prostate. Analyse critique des articles issus des ?tudes ERSPC et PLCO publi?s en mars 2009. Available at, http://www.has- sante.fr/portail/jcms/c_961182/depistage-du-cancer-de-la-prostate-analyse- critique-des-articles-issus-des-etudes-erspc-et-plco-publies-en-mars-2009
4 Braillon A, Dubois G. [PSA (prostate specific antigen): Haute Autorit? de sant?, American Cancer Society and National Health Service. Discrepancy between concepts for assessment]. Presse Med 2011; Jan (online Nov 5, 2010). Doi : 10.1016/j.lpm.2010.10.001
5 Braillon A. Prostate specific antigen. Prostate screening in France. BMJ. 2009 21;339:b4285
Ex senior tenured (2004 national exam, score: 150/150) consultant at Amiens University Hospital sacked in Sept 1st, 2010 with the approval of the National Management Centre (Department of Health) against the advice of the National Statutory Committee. (see "Abuse of libel laws and a sacking: The gagging of public health experts in France". http://blogs.bmj.com/tc/2010/11/08 from Pr G?rard Dubois, chairman of the Addiction Committee at the French Academy of Medicine).
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Hematology/Oncology, Prostate Cancer, Cancer Screening/Prevention, Prevention/Screening.
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