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Shared decision making still lacking for cancer screening

By Genevra Pittman

NEW YORK (Reuters Health) - When it comes to cancer screening, doctors often do not adequately discuss the balance of pros and cons with their patients, a new study suggests.

Guidelines call for doctors and patients to engage in shared decision making regarding cancer screening, such as whether to have prostate specific antigen (PSA) testing for prostate cancer.

That’s because although screening can help spot some cancers early on, it can also come with a risk of false positives and unnecessary and invasive follow-up procedures.

Often there is no right decision on whether to screen, and different people may weigh the options and their potential consequences differently, researchers said.

“Cancer screening and a number of other medical services are not all just plain benefit,” said Dr. Michael Pignone at the University of North Carolina at Chapel Hill, who worked on the new study.

“People should really know what they’re getting into,” he told Reuters Health.

Pignone said that in the past few years, a growing number of organizations like the American Cancer Society have pointed to the importance of shared decision making.

To see if that movement is being reflected in practice, the researchers analyzed data from a web-based survey that asked participants about their experiences with cancer screening.

The current study includes responses from roughly 1,100 adults ages 50 and over who had discussed a screening-related decision with a healthcare provider in the past two years. It focused on colon, breast and prostate cancer screening decisions.

Participants reported that between half and two thirds of the discussions covered the potential benefits of cancer screening. But less than one in ten conversations about breast or prostate cancer screening and only slightly more on colon cancer screening covered possible reasons not to get tested.

Between 27 and 38 percent of patients reported engaging in shared decision making with their provider, and another 45 to 69 percent said they were mainly responsible for making the final screening decision.

Depending on the screening test in question, between 69 and 93 percent of study participants chose to get screened, and most said they would make the same decision again, the authors write in the American Journal of Preventive Medicine.

But given that people were often not informed about potential risks, having confidence in the decision to undergo screening doesn’t guarantee it was the best choice, they point out.

Dr. Michael Wilkes has studied shared decision making at the University of California, Davis but was not involved in the new research.

“The bottom line is, doctors just aren’t doing this,” he told Reuters Health.

Brian Zikmund-Fisher, from the University of Michigan in Ann Arbor, said he and his colleagues saw similar results when they studied doctor-patient screening discussions five or six years prior to the current report.

“What this study does is it shows that despite all of the initiatives and the discussion of shared decision making that has been going on, we don’t seem to be moving the needle very much,” he told Reuters Health.

“The thing that I wish would be more part of the conversation is a recognition that there’s always a trade-off in cancer screening. It’s not perfect,” Zikmund-Fisher, who was not part of the research team, said.

Many times, the answer to whether a person should get screened will be yes, he added. “But that doesn’t mean we shouldn’t have the conversation.”

It’s not that doctors don’t want patients to make informed decisions, Pignone said. But some may think having a discussion isn’t worth it if they have their own beliefs about screening and not much time to spend with each patient.

“Some of us really like having these conversations. But for the vast majority, it’s a pain in the neck,” Wilkes said. “Most (doctors) think this is just some legal requirement, and it really isn’t, it’s a moral imperative.”

To encourage a shared decision making process, people should come into an appointment ready to ask questions about the benefits and downsides of screening and to talk about their own screening-related values, Pignone said.

“A prepared and informed patient is likely to get the most out of their encounter with their doctor,” he said.

SOURCE: http://bit.ly/1omdF3i American Journal of Preventive Medicine, online June 8, 2014.

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