Considerable controversy exists about the effectiveness of prostate specific antigen (PSA) screening in reducing mortality from prostate cancer (PCa), although there is good evidence that the PSA test can detect early stage prostate cancer. Moreover, there is evidence that screening is associated with important harms: frequent false-positive biopsies, anxiety, overtreatment of non-aggressive cancers. [1
]. Most organizations recommend that men should be given the opportunity to discuss the benefits and risks of PSA testing with their primary care providers (PCPs) before making a screening decision [2
Two recent reports of randomized trials of PSA screening have done little to resolve the screening controversy. One study showed no mortality benefit. The other identified a small impact of PSA testing on PCa mortality but was associated with considerable human and financial cost due to overtreatment [3
]. The controversy over whether PSA testing can significantly reduce PCa-specific mortality has resulted in some PCPs who strongly recommend PSA testing, some who strongly recommend against, and few who inform men about the pros and cons and share in the decision-making process. Men may also feel pressure from family, friends, public figures and the media, most of whom urge PSA testing. Given this confusing situation, informed decisions about whether one should or should not get a PSA test have never been more needed.
To make an informed decision, the US Preventive Services Task Force suggests that one should understand the risk or seriousness of the disease and the preventive service offered, one should understand its risks, benefits, alternatives, and uncertainties and one should weigh his values regarding potential harms and benefits before engaging in decision-making. Decision-making may be shared with one's provider and sharing may range from no sharing at all to ceding the decision making to the PCP [5
In general, decision aids help patients make informed decisions about a number of preventive measures and treatments. Several aids have been developed specifically to address PSA testing [6
]. O'Connor proposes that a good decision aid should: 1) improve knowledge of the problem, options, and outcomes, 2) create realistic expectations of outcomes, 3) clarify personal values for outcomes 4) promote congruence between values and choice, 5) reduce decisional conflict, 6) promote implementation of choices and 7) improve satisfaction with decision making [11
]. These standards seem to us and others [14
] to apply to decision-making around cancer control issues in general and PSA screening, in particular.
Evans et al. [16
] reviewed eight PCa screening decision aids and concluded that most aids increase knowledge and help subjects feel more confident about their decision. Several reviews confirm that PCa screening decision aids generally increase patient knowledge, decrease decisional conflict, and/or increase greater involvement in decision-making [17
]. A Cochrane review of decision aids concluded that PCa screening decision aids also appear to decrease interest in PSA testing [17
]. Few studies of PCa screening decision aids have included measures of decision congruence with the patient's preferences and values. Most aids do not promote shared decision-making or define a role for the PCP. Two studies that do address these issues are: a) a randomized trial of a web-based decision aid compared to publicly available websites that showed better congruence of men's decisions and their values after reviewing the web-based aid [19
] and b) a video decision aid that showed men who had decided not to be screened were less likely to discuss their decision with their PCP compared to men who had decided otherwise [20
Telephone counseling has been successful in many health promotion efforts focused on moving individuals to a desired health behavior such as having regular screening mammograms. But, to our knowledge, it has not focused on the outcome being an informed decision, rather than a specific desirable behavior [21
]. Decision making about PCa screening is complex because the value of PCa screening is unproven. A PCa screening decision aid should therefore not
promote screening but rather promote informed decision making that is congruent with a man's values and understanding, regardless of whether the decision is for or against screening. A decision aid may also serve to complement discussion with one's PCP, although few engage in balanced discussions and most do not discuss the negative aspects of PSA testing [30
The purpose of the pilot study reported here was twofold: 1) to evaluate the effectiveness of computer-assisted telephone counseling (CATC) as a decision aid for men considering PSA testing and 2) to present a testable surrogate for discussion and decision sharing with one's PCP. The more common model of informed decision making includes a decision aid (print, video, etc.) with no or limited live interaction between decision aid and subject, sometimes followed by discussion and/or shared decision making between patient and PCP. Our intervention is distinguished from other decision aids by the use of a CATC system and a counselor who played several roles: educator, facilitator of values clarification, and motivational interviewer. Our study is also distinguished from many other studies of informed decision making by the inclusion of measures of stage of readiness and stage change, perceived vulnerability, decisional conflict, decisional satisfaction, as well as pros and cons scores to quantify values, and the difference between pros and cons scores to quantify the consistency of values with the PSA decision made.