Medical Decision Making
Mediated decision support in prostate cancer screening: A randomized controlled trial of decision counseling

https://doi.org/10.1016/j.pec.2010.06.011Get rights and content

Abstract

Objective

This randomized trial was conducted to assess the impact of a mediated decision support intervention on primary care patient prostate cancer screening knowledge, decisional conflict, informed decision making (IDM), and screening.

Methods

Before a routine office visit, 313 male patients eligible for prostate cancer screening completed a baseline telephone survey and received a mailed brochure on prostate cancer screening. At the visit, participants were randomized to either an enhanced intervention (EI) or a standard intervention (SI) group. Before meeting with their physician, EI Group men had a nurse-led “decision counseling” session, while SI Group men completed a practice satisfaction survey. An endpoint survey was administered. Survey data, encounter audio-recordings, and chart audit data were used to assess study outcomes.

Results

Knowledge increased in the EI Group (mean difference of +0.8 on a 10-point scale, p = 0.001), but decisional conflict did not change (mean difference of −0.02 on a 4-point scale, p = 0.620). The EI Group had higher IDM (rate ratio = 1.30, p = 0.029) and lower screening (odds ratio = 0.67, p = 0.102).

Conclusion

Nurse-mediated decision counseling increased participant prostate cancer screening knowledge, and influenced informed decision making and screening.

Practice implications

Nurses trained in decision counseling can facilitate shared decision making about screening.

Introduction

In 2010, there were an estimated 217,730 new cases of prostate cancer in the United States, and 32,050 deaths from the disease, making it the second leading cause of cancer-related death among men [1]. Prostate cancer is often diagnosed through prostate cancer screening, which includes digital rectal examination (DRE) and prostate specific antigen (PSA) testing.

Unfortunately, definitive evidence is lacking regarding the impact of screening on mortality and survival; screening carries a substantial risk for over-diagnosis; and there are serious complications associated with treatment for early-stage disease [2], [3], [4], [5]. A recent report from a large randomized trial conducted in the United States found that prostate cancer screening does not save lives [6], while data from a large European trial showed that screening may produce a modest reduction in mortality [7]. Both trials concluded, however, that mass screening with PSA results in substantial over-diagnosis and related morbidity. A recent report using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program is consistent with this view [8].

Current prostate cancer screening guidelines recommend that informed, shared decision making should be part of routine primary care for older adult men [9], [10], [11]. In practice, however, most men have little or no discussion about prostate cancer screening with a primary care provider [12]. Given this state of affairs, there is a pressing need for methods to facilitate informed and shared decision making about prostate cancer screening use [13]. Decision aids (e.g., print materials, telephone contacts, videos, and Internet tools for providing information), have been investigated as a means to increase patient prostate cancer screening knowledge and involvement in decision making about screening [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. The studies have sought to assess decision aid impact on patient knowledge, decisional conflict, and screening use.

This report presents findings from a randomized controlled trial, referred to as the Decision Counseling Trial (DCT). The DCT was designed to test the impact of nurse-mediated decision support on patient prostate cancer screening knowledge and decisional conflict (primary outcomes) and on informed decision making and actual screening use (secondary outcomes).

Section snippets

Study setting, participants, and procedures

The DCT was conducted between 2003 and 2007 with patients at two primary care practice sites in Philadelphia, PA. Patients included in the study were males who were 50–69 years of age, had no history of prostate cancer or benign prostatic hyperplasia (BPH), and did not have a PSA test in the previous 11 months. The trial was approved by the Institutional Review Boards of Thomas Jefferson University and the Einstein Health Care System in Philadelphia, Pennsylvania.

Prior to patient recruitment to

Results

Fig. 1 summarizes study accrual and randomization. In 30 months, we screened 2234 patients, determined 1245 were potentially eligible, contacted 891, and administered a baseline survey to 436. Of those patients surveyed, 313 (72%) were randomly assigned, either to the EI Group (n = 156) or the SI Group (n = 157). Decision counseling sessions for the EI Group men averaged 28 min (standard deviation = 14). On the endpoint survey, 97% of the EI Group respondents reported that they remembered discussing

Discussion

Our analyses show that prostate cancer screening knowledge at baseline was low and that knowledge at endpoint had increased among men in both study groups. This increase may be the result of exposure to the informational brochure sent to all participants before their office visit. However, we also found that the gains in knowledge were significantly greater in the EI Group than in the SI Group. Nurse educator review of the brochure in the decision counseling session is likely to have boosted

Acknowledgements

The Decision Counseling Trial was conducted under AAMC/CDC cooperative agreement grant MM-0554-03. The authors declare that there are no conflicts of interest. We wish to extend our sincere thanks to Dr. James Dolan his most valuable contributions as a consultant on the study and to Ms. Heidi Swan for her extremely helpful efforts in manuscript organization and editing.

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