All GPs in the study reported having some degree of discussion about PSA testing with asymptomatic men who consulted with concerns about prostate cancer. However, we found considerable variation within the reported discussions, with a tendency for greater emphasis to be placed on certain key points and disparity in the degree of detail given. We also identified differences in the impartiality with which GPs appeared to present the information.
Content of GPs' discussions with men
False-positive and false-negative results
The GPs in our study described feeling that it was important for men to understand the imprecise nature of the PSA test, and, without exception, they reported having discussed the possibility of the PSA test yielding false-positive and false-negative results.
"I normally tell them that men with prostate cancer usually have high levels of PSA and men without prostate cancer usually have low levels but there are some men who have higher than normal levels who don't have prostate cancer and some men who've got quite low levels who turn out that they do have prostate cancer..." ID19
The biopsy stage
Many GPs said they would explain that the PSA test alone is not sufficient to diagnose prostate cancer and a prostate biopsy is the probable next stage following a raised PSA result.
"...it's usually part of my talk that ... if it is positive then the only way we go further and know for sure would be a biopsy..." ID10
However, the uncertainty of what to do if the PSA result is only slightly raised, is also often discussed.
"...[I talked] about the false-positives and negatives, and the problem of marginally raised results, what to do with it. The difficulties in deciding what to do with a slightly raised PSA ....." ID3
GPs frequently reported discussing the potential pain and discomfort of a biopsy. Less often they described mentioning that some biopsies are unwarranted due to false-positive PSA results, and that false reassurance can result from false-negative biopsy results.
"...[I say that] it's not a very good test and it's, there's a fair chance that it'll show up positive and you won't have any prostate cancer ... so that can land you in all sorts of unpleasant biopsies and things for nothing." ID17
While many GPs reported that they would discuss issues related to a prostate biopsy, there was considerable variation in the degree of detail that they said they give. Some would provide minimal information.
"...do you actually mention the possibility of having to have a biopsy if the PSA is raised ...? I'm not sure I get as far, I would say "If it's raised and it's raised enough that we need to refer you for more investigations," and I think that would be as far I would get..."ID2
Others report giving much more expansive descriptions.
"... then I go on a bit to talk about biopsies... that when they do an ultrasound test they can sometimes see an area of abnormality in which case they can biopsy that area..... but if they can't see any areas of abnormality then they take six or eight blind biopsies and the results of those biopsies can be again normal or abnormal. And when they're normal then that's usually reassuring but of course if you're taking blind biopsies you may have missed the area of abnormality......and so it can never be absolutely foolproof ..." ID18
Potential for diagnosis of indolent cancers
While less frequently discussed than the previous key points, a number of GPs said they would discuss the variable nature of prostate cancer, with an emphasis on the possibility of identifying indolent cancers which may never cause a problem.
"... my usual line is, when old boys die an awful lot of them have been found to have prostate cancer that they had no idea was there and has never caused a jot of problems...and I try and explain that to them 'You may turn out to have the prostate cancer that is just going to sit there for thirty years and do nothing...' " ID15
GPs who said that they either would not include a discussion of the range and nature of prostate cancers, or would do so in a very limited way, gave several reasons for this. Some felt that this information is often not relevant to men at this stage of the process.
"I feel I'm in second line for that (discussion of range of prostate cancers) because if they go ahead and have the biopsy, say they have the PSA test and it's positive then you have to, you are obliged to refer ... the urologists are obliged then to investigate further.....so it's very much their stance isn't it?" ID8
Some GPs believe this information is less relevant for younger men, as having prostate cancer at an early age is more likely to have serious implications.
"I think it's useful in the elderly...but I don't think it's useful in someone aged 50...because they, if they did get diagnosed with prostate cancer at 50 then they probably would die of it..." ID16
Treatments for prostate cancer
Very few GPs in the study reported discussing treatment options for early prostate cancer. Those who did said they would tend to emphasise the potential side effects and lack of consensus about which treatments, if any at all, may be effective.
"I think people need to realise ...even if it is diagnosed, as far as I know there is still uncertainty as to what the best treatment is even so if you know you've got it, it's hard to know what to do about it" ID19
Again, relevance of the information to men at this stage of the process was cited as a reason for omitting treatment option discussions.
"you only have a limited consultation ...you don't want to frighten people if they haven't got it, like you don't say to every woman before they go for a mammogram all the pros and cons of chemotherapy and radiotherapy for breast cancer do you?" ID7
GPs reported very little corresponding discussion about how treatment could be potentially beneficial.
"... I don't go into all the detail about what the various treatment options are... just to say that there are effective treatments particularly if it's caught early which is the rationale really for screening for it". ID14
Several factors which had an impact on what was discussed within the consultations are specific to the PSA test and have been considered in the relevant sections above; others factors relate to primary care consultations in general.
The amount of detail discussed was affected by the use of written information. Some GPs found patient information leaflets a useful supplement to, or in some cases, a replacement for detailed discussion.
-"...so you tend to give the leaflet out? Oh always. Do you think that is the best way to provide patient information, for GPs? Um well I think the evidence is that people don't remember what you say to them ... and it also means that you know wives and families generally have a chance to share it, so I know I'm also, everything that can be given in leaflet form should be really" ID13
Explaining and ensuring an understanding of the key points was felt by many GPs to be a time consuming process. Some felt that a ten minute consultation, focussing only on the PSA test, may give sufficient time to convey the main points, though this would not be so if more than one concern is brought to a consultation and the issue of PSA testing raised at a late stage. Other GPs felt that even a full 10 minute consultation would not be sufficient.
"I don't know if our language has developed enough with patients nor their, nor their thoughts. I think, I think they're difficult concepts.....So I think, I think getting a patient to, to a position of truly informed decision-making is, is difficult and it is very time consuming and maybe that's the problem, maybe I just feel we haven't got the time to spend with every patient doing that" ID5
Degree of balance in discussion
GPs' opinions about the PSA test
We found differences in the way GPs described how they present information to men, which in part seems to reflect the wide range of opinions held about the usefulness of the PSA test as a screening tool. Some GPs who expressed strong views against the value of the PSA test, quite clearly portray this view to men in their discussions, either directly:
" ...I think I would really give very directive counselling and try and talk them out of it and say "It's a waste of time and really I advise against it." ID17
or indirectly, by highlighting the drawbacks:
"... I do tend to talk about the impossible situation you get yourself into if you have a PSA that's raised. You're going to then not know whether to have prostate biopsies and so on... and all the risks of that... so that's how I tend to try to put them off..... by saying 'The chances are it will come back in some unhelpful grey area and you won't know what to do...' " ID13
GPs who have either neutral, or more positive views about the usefulness of PSA screening tend to present men with information on the benefits and limitations of testing, with the intent of allowing the men to reach their own decisions. One such GP, who provided very full information on testing, did note that most men he counselled went on to be tested.
"I'm probably a bit pro-testing ... I don't positively dissuade them as it were, I give them all the information and they usually go on to have a test, I would say ...". ID18
Men's prior opinions of PSA testing
Men's predominantly positive attitudes towards PSA testing, often due to press coverage or personal recommendation, also often had an effect on the way GP's presented the information. GPs described emphasising the drawbacks of testing, thus presenting somewhat biased information to counter the faith men appeared to place in the test.
"...and people in general are quite keen to have, men in general are quite keen to have a prostate blood test.....unfortunately... [laughs]... I certainly sound negative about it to counteract the over-positive things that they've read ..." ID4
Impact of balance on GP's behaviour
While personal views about PSA testing seem to be an important factor in determining how impartial GPs are in presenting information, and many GPs did say they would attempt to dissuade men from being tested, only one GP in our study said he would deny a man's request, and that related specifically to men under the age of 50. Concerns about being held responsible for missing a cancer affected the tendency for some GPs to dissuade a man from undergoing a PSA test. The following GP said he would highlight the negative elements of testing to men, but would carry out a test if they persisted in their request.
"...people have read about it (PSA test) and are convinced it's the bees knees ...and if you don't do it and it turns out that subsequently you could have detected prostate cancer I think you know you, you're going to be on a sticky wicket..." ID15