The controversy over prostate-cancer screening

Psychologists help men make decisions about undergoing screening tests for prostate cancer.

By Bridget Murray
Monitor staff

For some cancers, particularly breast and cervical cancer, the benefits of screening are obvious. If cancerous cells are revealed, patients can opt for surgery or other forms of treatment to have them removed. For many, life after treatment can resume much as it did before.

For prostate cancer, though, the screening for which involves a blood test and digital rectal exam for asymptomatic men, a positive result could be false. Moreover, a positive result often compels patients to undergo biopsy, and perhaps surgery or radiation that doesn't necessarily remove all the cancer, isn't proven to reduce their disease-related mortality and possibly leaves them with impotence and incontinence.

Some medical experts don't even think men should get screened because a positive result triggers a difficult decision about whether to undergo surgery or radiation. And the treatment could result in uncomfortable side effects, but may not lengthen life. This is because prostate cancer can grow slowly and may not ever cause clinical symptoms.

Yet others in medicine say it's always best to be screened and always best to get treated. They note that the prostate operation or radiation can remove the localized cancer completely, and doesn't always mean a negative aftermath.

The decision men make about screening often depends on the health professional they talk to, says Kathryn Taylor, PhD, a psychologist studying the issue at Georgetown University Medical Center's Lombardi Cancer Center. And the ambiguity poses an unclear choice for men, particularly older African-American men, for whom the risk is highest.

Informed choices

That's where Taylor and other psychologists come in, attempting to ease men's discomfort over the lack of clarity through explanation of the controversy and information about options. Taylor and another psychologist, Robert Hamm, PhD, are using their cognitive backgrounds to inform men about the choices and outcomes that prostate screening involves. Their aim is to help people make the screening decision that suits them best.

"It's uncomfortable for men to learn that doctors don't agree about the utility of prostate screening," says Taylor. "The goal of patient education strategies is to communicate the specifics of this without provoking even more anxiety."

Part of the job, she says, is explaining the myriad potential outcomes:

* Some men screen positive and elect surgery, when the cancer would not have advanced to cause symptoms or death.

* Some men screen positive and don't have any cancer cells, meaning they have a "false positive." They may fear they have cancer until they have a potentially painful biopsy, which shows they don't have the disease.

* Some men who screen positive and elect surgery avert advanced cancer as a result.

* Some men screen positive, elect surgery and get metastatic cancer, meaning it spreads to other parts of the body, anyway.

* Some men screen negative when cancer cells are actually present at the time of screening, what's known as a "false negative."

"This is hard for physicians to discuss with patients because they can't say what patients should do universally and aren't sure what to tell them," says Hamm, of the University of Oklahoma's College of Medicine. "That's why they've called on psychologists to help explain it. We can help people evaluate outcomes they haven't experienced, help them understand their choices. "

At present, many men decide to undergo screening of their own volition, Taylor and several colleagues found in a study published earlier this year in the journal Cancer (Vol. 85, No. 2, p. 1305_1312). And what most concerns Taylor is that most men don't know about the screening controversy, and "assume that screening is always the best decision." Many aren't aware of the high incidence of false positives and the difficult decision about whether to seek treatment that comes from a positive result.

More research

In addition to other research--including a study of the psychological effects of false-positive screening for prostate cancer--Taylor is collaborating with several others in a study of prostate cancer screening funded by the U.S. Centers for Disease Control and Prevention (CDC). Her colleagues include psychologist Jon Kerner, PhD, also of Georgetown University Medical Center, CDC sociologist Joan Kraft, PhD, and urologist Jackson Davis, MD, and Ralph Turner, both of the Most Worshipful Prince Hall Grand Lodge of the District of Columbia, an African-American Masons organization.

The team is conducting focus groups to assess what men know and want to know about prostate cancer screening. It's also finding out from men the best ways to communicate what they don't know--through videos, written pamphlets or other media. The second phase of the study will assess the effectiveness of the educational materials in a randomized trial with a sample of Masons in the District.

For his part, Hamm is conducting similar CDC-funded research on white, Hispanic and African-American men. Also in the early phases of the project, he and several colleagues, including sociologist Stephanie McFall, PhD, also at Oklahoma, psychologist Robert Volk, PhD, of the Baylor College of Medicine and CDC's Kraft, are determining what facts and decision-making strategies men need to make informed screening choices.

"We are exploring ways to help men weigh their options by providing them with information from a medical decision analysis framework," says Hamm. "We show them how many men in their situation might experience the different possible outcomes. We expect this will help them move from confusion to decision."

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