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A Simple Schema for Informed Decision Making About Prostate Cancer ScreeningSimple Schema for Informed Decision Making About Prostate Cancer Screening

Andrew J. Vickers, PhD; Kelly Edwards, PhD; Matthew R. Cooperberg, MD, MPH; and Alvin I. Mushlin, MD, ScM
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From Memorial Sloan Kettering Cancer Center and Weill Cornell Medical Center, New York, New York; University of Washington School of Medicine, Seattle, Washington; and UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.

Grant Support: This work was supported by the National Cancer Institute (R01CA160816, R01 CA175491, and P50-CA92629), the Sidney Kimmel Center for Prostate and Urologic Cancers, and David H. Koch through the Prostate Cancer Foundation. Dr. Mushlin was supported in part by grant UL1 RR024996 from the National Center for Research Resources of the National Institutes of Health (Clinical and Translational Science Center award). Dr. Edwards was supported in part by the Centers for Disease Control and Prevention (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).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0151.

Requests for Single Reprints: Andrew J. Vickers, PhD, Memorial Sloan Kettering Cancer Center, 307 East 63rd Street, 2nd Floor, Box 44, New York, NY 10065; e-mail, VickersA@mskcc.org.

Current Author Addresses: Dr. Vickers: Memorial Sloan Kettering Cancer Center, 307 East 63rd Street, 2nd Floor, Box 44, New York, NY 10065.

Dr. Edwards: Department of Bioethics and Humanities, University of Washington School of Medicine, Box 357120, Seattle, WA 98195.

Dr. Cooperberg: University of California, San Francisco, Box 1695, 1600 Divisadero Street, A-607, San Francisco, CA 94143-1695.

Dr. Mushlin: Weill Cornell Medical Center, Department of Public Health, 402 East 67th Street, New York, NY 10065.

Author Contributions: Conception and design: A.J. Vickers, K. Edwards.

Analysis and interpretation of the data: A.J. Vickers, A.I. Mushlin.

Drafting of the article: A.J. Vickers, K. Edwards, M.R. Cooperberg, A.I. Mushlin.

Critical revision of the article for important intellectual content: A.J. Vickers, K. Edwards, M.R. Cooperberg, A.I. Mushlin.

Final approval of the article: A.J. Vickers, K. Edwards, M.R. Cooperberg, A.I. Mushlin.

Ann Intern Med. 2014;161(6):441-442. doi:10.7326/M14-0151
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Prostate-specific antigen (PSA) screening for prostate cancer is a problematic aspect of primary care. Most guidelines recommend informed decision making by the patient after a discussion with a physician, but how to best implement such decision making is unclear. The authors propose an approach for informed decision making about PSA testing that is evidence-based, facilitates a discrete decision, and is appropriate for primary care settings.

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Posted on October 15, 2014
O'Callaghan, M.E., Kichenadasse, G, Vatandoust, S, Moretti, K.L.
Repatriation General Hospital, The South Australian Prostate Cancer Clinical Outcomes Collaborative,The University of Adelaide
Conflict of Interest: None Declared
We read with interest Vickers’ article recently published in The Annals (1). We note one of the key facts which is to be presented to patients in order to make an informed decision regarding PSA screening:
“Although only a small proportion of men with prostate cancer die of the disease…”
We do not believe this statement accurately conveys the proportion of deaths attributable to PCa in the context of counselling men considering PSA screening.
PCa is the second most common cause of male cancer death in Australia, USA, UK and many EU countries. Many countries outside the US do not have high uptakes of PSA screening and a significant proportion of men with PCa die of the disease. Even in the USA self-reported PSA screening rates range from 59.4% (Hawaii) to 24.5% (New Hampshire)(2).
SEER data supports ten year mortality rates of 6.1% for PCa (patients diagnosed with localised disease) and 29.2% for other causes (3). This suggests PCa accounts for 17.2% of all deaths in these men in the first ten years after diagnosis. As this data relates to a group of men likely to have been screened, it is only part of the picture. An indication of the proportion of deaths due to PCa taken from men who have not been screened is also required.
Chowdhury (4) report causes of death in a UK cohort (50,066 men) were PCa was the cause of death in 49.8%. Localized PCa was reported in 27,717 (55.4%) and PCa accounted for 35.7% of all deaths in this group. In men aged <65 (n=10,992) the all-cause mortality was 17.8% with PCa being recorded as the cause of death in 65.6%. Ten year cumulative incidence plots present a consistent message.
Our local Australian data from the South Australian Prostate Cancer Clinical Outcomes Collaborative identified 577 (38.7%) of reported deaths as attributable to PCa among a cohort of 7,018 men with PCa (unpublished). Cumulative incidence of PCa specific mortality at ten years was 15% and accounted for 36.5% of all deaths.
In populations where PSA screening is less common, a somewhat larger proportion of men with PCa may die of the disease. The advice "a small proportion of men with prostate cancer die of the disease" should be stated cautiously as this may lead to a decrease in screening rates and offers of curative treatment, potentially increasing mortality.

1. Vickers AJ, Edwards K, Cooperberg MR, Mushlin AI. A simple schema for informed decision making about prostate cancer screening. Ann Intern Med. 2014;161(6):441-2.
2. Sammon JD, Pucheril D, Diaz M, Kibel AS, Kantoff PW, Menon M, et al. Contemporary Nationwide Patterns of Self-reported Prostate-Specific Antigen Screening. JAMA Intern Med. 2014.
3. Abdollah F, Sun M, Thuret R, Jeldres C, Tian Z, Briganti A, et al. A competing-risks analysis of survival after alternative treatment modalities for prostate cancer patients: 1988-2006. Eur Urol. 2011;59(1):88-95.
4. Chowdhury S, Robinson D, Cahill D, Rodriguez-Vida A, Holmberg L, Moller H. Causes of death in men with prostate cancer: an analysis of 50,000 men from the Thames Cancer Registry. BJU Int. 2013;112(2):182-9.

Author's Response
Posted on November 11, 2014
Andrew J.Vickers, PhD
Conflict of Interest: None Declared

The statement at issue is “only a small proportion of men with prostate cancer die of the disease”. We stand by this statement and remain unclear as to the relevance of citing data from a largely unscreened population, as the denominator will not include many men with biopsy detectable cancer (i.e. “men with prostate cancer”).

The purpose of the statement is to reorient patients away from any perception that prostate cancer is generally fatal. There are empirical data that this perception is widespread[1].

The authors suggest that our statement will, of itself, “lead to a decrease in screening rates”. We find this questionable, especially as the statement is immediately followed by the assertion that “screening reduces the risk for prostate cancer death”.

That said, our recommendation is a schema, not a script. It would be perfectly reasonable to adapt the schema to local circumstances, or for an individual clinician to choose words based on what he or she felt best reflected the research evidence. For instance, we cannot foresee any objection to stating “only a fraction of men with prostate cancer die of the disease” or “most men with prostate cancer die with rather than from disease”.

1. Gigerenzer G, Mata J, Frank R. Public knowledge of benefits of breast and prostate cancer screening in Europe. J Natl Cancer Inst. 2009 Sep 2;101(17):1216-20.

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