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Shared decision-making before prostate cancer screening decisions

Nature Reviews Urology (2024)Cite this article

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Abstract

Decisions around prostate-specific antigen screening require a patient-centred approach, considering the benefits and risks of potential harm. Using shared decision-making (SDM) can improve men’s knowledge and reduce decisional conflict. SDM is supported by evidence, but can be difficult to implement in clinical settings. An inclusive definition of SDM was used in order to determine the prevalence of SDM in prostate cancer screening decisions. Despite consensus among guidelines endorsing SDM practice, the prevalence of SDM occurring before the decision to undergo or forgo prostate-specific antigen testing varied between 11% and 98%, and was higher in studies in which SDM was self-reported by physicians than in patient-reported recollections and observed practices. The influence of trust and continuity in physician–patient relationships were identified as facilitators of SDM, whereas common barriers included limited appointment times and poor health literacy. Decision aids, which can help physicians to convey health information within a limited time frame and give patients increased autonomy over decisions, are underused and were not shown to clearly influence whether SDM occurs. Future studies should focus on methods to facilitate the use of SDM in clinical settings.

Key points

  • Shared decision-making (SDM) about prostate-specific antigen screening should be collaborative between patients and physicians, and should consist of eliciting patients’ preferences, providing evidence-based information about risks and benefits, and reaching a values-concordant choice.

  • The use of SDM for prostate cancer screening is suggested by guideline groups, but SDM remains underused.

  • Facilitators to SDM include a consistent clinician–provider relationship, trust in the clinician, having a partner, and high education level.

  • Barriers to SDM include limited appointment times, insufficient knowledge, poor health literacy, any barrier to communication, and physician beliefs about screening.

  • Decision aids can help to improve patients’ knowledge and facilitate SDM, but are rarely used in clinical practice.

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Fig. 1: Model of full shared decision-making for PSA screening.

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Acknowledgements

We sincerely thank Johanna Goldberg, research informationist, for assistance with the literature search. We express our gratitude to Dr. Laura Liberman, Office of Faculty Development, Memorial Sloan Kettering Cancer Center, New York, USA, for the 2021 Summer Clinical Oncology Research Experience (SCORE) Program that enabled D.K.S.’s work on this study. The work of K.R.P., D.K.S., M.A. and S.V.C. on this paper was supported in part by funding from the National Institutes of Health/National Cancer Institute (P30 CA008748). S.V.C. was supported by NIH/NCI grant (K22 CA234400). K.R.P. was supported in part by the Ruth L. Kirschstein National Research Service Award (T32 CA082088).

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Authors and Affiliations

  1. Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Kelly R. Pekala & Sigrid V. Carlsson

  2. Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Daniela K. Shill

  3. Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Mia Austria & Sigrid V. Carlsson

  4. Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA

    Aisha T. Langford

  5. Department of Population Health, New York University, New York, NY, USA

    Stacy Loeb

  6. Department of Urology, New York University and Manhattan Veterans Affairs Medical Center, New York, NY, USA

    Stacy Loeb

  7. Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

    Sigrid V. Carlsson

  8. Department of Translational Medicine, Division of Urological Cancers, Medical Faculty, Lund University, Lund, Sweden

    Sigrid V. Carlsson

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Correspondence to Sigrid V. Carlsson.

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S.V.C. has received travel reimbursement and an honorarium from Ipsen and has served on an advisory board for Prostatype Genomics. The other authors declare no competing interests.

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Pekala, K.R., Shill, D.K., Austria, M. et al. Shared decision-making before prostate cancer screening decisions. Nat Rev Urol (2024). https://doi.org/10.1038/s41585-023-00840-0

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