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An Overview of Prostate Cancer Screening Recommendations and Shared Decision-Making Process Model to Guide Nursing Practice.

Some empirical studies have found prostate cancer screening is beneficial, while others have conceded it is not consequential and can even be harmful to patients' health (Gabrani, Knibb, Petrela, Hoxha, & Gabrani, 2016; Schroder et al., 2014). An overview of prostate cancer screening guidelines is offered, with a guide proposed to help providers implement the shared decision-making process with patients before screening.

According to the American Cancer Society (ACS, 2017a), prostate cancer is the most frequently diagnosed malignancy in males in America and the third leading cause of death in men (estimated 26,730 deaths in 2017). Additionally, the ACS suggested the incidence of prostate cancer spiked significantly due to the use of the prostate specific antigen (PSA) test in the late 1980s and early 1990s. From 2009 to 2013, the incidence of prostate cancer declined about 8% per year, mostly due to ACS recommendations against routine screening with the PSA test. The ACS reported approximately 161,360 new cases of prostate cancer in 2017.

PSA and Digital Rectal Exam Screening Tests

Qaseem, Barry, Denberg, Owens, and Shekelle (2013) acknowledged the PSA test was more sensitive than the digital rectal exam (DRE) for prostate cancer screening. Although the PSA currently is used in primary care settings as a preferred tool to screen for prostate cancer, it has low specificity and sensitivity, and it does not determine the threshold to warrant a biopsy (Zheng et al., 2015). Practitioners should be educated about the PSA and DRE tests to discuss their associated limitations with patients before screening.

Advantages and Disadvantages of Prostate Cancer Screening

The impact of prostate screening on decreasing mortality is not clear (Kim & Andriole, 2015). Two screening trials were the center of the controversy about effectiveness of the PSA test or DRE in reducing prostate cancer mortality. The first clinical trial was the European Randomized Study of Cancer (ERSPC), which lasted over 10 years (Schroeder et al., 2014). This trial was conducted with 162,388 participants ages 55 to 69. The ERSPC found a reduction in prostate cancer mortality due to PSA testing. Screened participants had 21% mortality compared to 27% in the control group.

The second clinical trial, the Prostate, Lung, Colorectal and Ovarian Screening Trial (PLCO), occurred in the United States. The PLCO trial surveyed 76,693 men ages 55 to 74 over 13 years. Results indicated no significant benefits of prostate cancer screening (e.g., PSA) as it did not decrease cancer mortality among participants (Livingston et al., 2016; Qaseem et al., 2013). Researchers from the PLCO trial found more deaths occurred in the group screened using the PSA. Given the conflicting findings, there is a need for shared decision making in primary care settings when providers pre-screen patients.

Overdiagnosis, Overtreatment Based on Prostate Cancer Screening

Empirical studies have found the utility of prostate cancer screening tests to be controversial (Alberts, Schoots, & Roobol, 2015; Loeb et al., 2014). Although the use of the PSA may contribute to a reduction in advanced prostate cancer disease, some inherent harms exist in the results of the screening process (Cuzick et al., 2014; Loeb et al., 2014). An elevation in PSA is not always indicative of cancer. According to Cuzick and co-authors (2014), a PSA test can show a false-positive result which can lead to overdiagnosis and overtreatment (American Urological Association [AUA], 2015; U.S. Preventive Services Task Force [USPSTF], 2018). For instance, a false-positive result indicates the PSA level is increased, but no cancer is present. Such a false-positive test result could produce anxiety and the need for unnecessary procedures (Gabrani et al., 2016). Further exploration is a biopsy with possible complications of infections, bleeding, pain, and even death. In empirical studies, over-treatments were found to increase harm and unnecessary healthcare costs, and worsen patients' outcomes (Etzioni, Gulati, Mallinger, & Mandelblatt, 2013; Loeb et al., 2014).

Prostate Cancer Screening Guidelines

Carter and co-authors (2013) noted that as medical knowledge evolves, so do prostate cancer screening guidelines. Orom and colleagues (2015) also acknowledged the controversy about the guidelines for prostate cancer screening caused patients to have decreased trust in health information. Practitioners thus need to be able to provide accurate information about guidelines for prostate cancer screening to help patients make informed decisions.

U.S. Preventive Services Task Force

The USPSTF (2018) recommended men ages 55 to 69 make an individual decision about prostate cancer screening with their clinician. The Task Force recommended against routine screening for men age 70 and older. Prostate cancer is a slow-growing cancer, which may remain dormant for years before overt symptoms develop. Consequently, patients may be symptom-free during their lifetime because the cancer is not detectable. According to the USPSTF, prostate cancer may be considered clinically unimportant to treat. The diagnosis and treatment of insignificant prostate cancer tumors may cause more harms than benefits and might lead to possible treatment dilemma. The USPFTS also argued the decision to screen relies on the provider's discretion to implement a shared decision-making process to inform a patient about prostate cancer screening risks and benefits.

American College of Physicians (ACP)

The ACP emphasized not screening men who are at average risk, under age 50 and over 69, or with a life expectancy of less than 10-15 years (Qaseem et al., 2013). The ACP also noted PSA testing was not beneficial because some prostate cancers were not clinically significant enough to be treated. Thus, more harm might occur when treating an indolent tumor that might not progress biologically. The ACP further advised practitioners to share testing information with higher-risk male patients starting at age 40, as well as those with multiple family members diagnosed with prostate cancer before age 65. The ACP also emphasized the need for broad review of existing guidelines for prostate cancer screening before offering any tests to patients. Finally, careful assessment of patients' general well-being, individual risk factors, and preferred method of screening was encouraged.

American Cancer Society

The ACS (2017b) supported the discussion of PSA testing starting at age 50 for average-risk patients with a life expectancy of 10 or more years. Discussion of screening for prostate cancer should occur with high-risk patients before age 45. These patients include African-American men with a first-degree relative (e.g., father, brother, son) diagnosed with prostate cancer before age 65. Further, the ACS recommended discussion of screening with patients at even higher risk at age 40, and those with more than one first-degree relative diagnosed with prostate cancer at an early age. If the patient decides to be screened after the discussion, he should be tested with the PSA.

American Urology Association

The AUA (2013) did not recommend screening men age 70 and older. The AUA advised not to test for early detection of prostate cancer in asymptomatic patients age 40 or older with a life expectancy of more than 10 years. Additionally, AUA recommended providers implement a shared decision-making process regarding PSA testing for men ages 55-69. Shared decision making involves practitioners and patients working in collaboration to select an agreeable treatment plan. Practitioners need to implement this process to support patients' decisions based on their preferences and values during prostate cancer screening.

Shared Decision-Making Process

A shared decision-making process helps inform and involve a patient in his care (Elwyn et al., 2012). It supports his decisions concerning screening, which might become a challenge for the patient. During a shared decision-making session, educating the patient about screening for prostate cancer is crucial. Education helps him make informed decisions about testing based on the values he places on outcomes of testing. Providers play a substantial role in a patient's screening decisions, and must provide accurate information for the patient to make a screening decision.

The value of shared decision making has been recognized increasingly during screening for prostate cancer (Cuypers, Lamers, Kil, van de Poll-Franse, & de Vries, 2015; Smith et al., 2015). It decreases patients' burden when making decisions about screening (Shen et al., 2015). Although shared decision making is suggested during screening, a gap exists between its guidance and application (Elwyn et al., 2012). Healthcare providers should implement a process similar to the Shared Decision-Making Model (see Figure 1) in clinical practice so patients will be able to commit to a treatment plan.

Shared Decision Model

Elwyn and co-authors (2012) proposed a model of shared decision-making for practitioners to navigate the challenges of screening for prostate cancer in clinical practice. This model has three concepts: introducing choice, describing options, and helping patients explore preferences and make decisions.

Choice talk. The choice talk presents available options to patients (Elwyn et al., 2012). Its components are "step back, offer choice, justify the choice, check reaction and defer closure" (p. 1363). This process helps patients understand their choices before confronting the challenges of making screening decisions for prostate cancer. In this phase, a patient's decision making may be facilitated with visual aids, pamphlets, or videos. For example, the practitioner may offer a video on prostate cancer screening to help a patient create a mental picture before reaching a decision for screening. The ACS (2017c) also offered a decision aid to increase prostate cancer screening knowledge among at-risk men. Providers could use this decision aid to help patients make their choices to screen for prostate cancer.

Option talk. The option talk presents information available to patients for prostate cancer screening. Its components are "check knowledge, list options, describe options, harms and benefits, provide patient decision support and summarize" (Elwyn et al., 2012, p. 1364). The option talk construct requires judgment from patients to make or break their decisions to be screened. During the option talk, nurse practitioners could discuss benefits and harms of screening (e.g., overdiagnosis, overtreatment, false-positive or false-negative PSA results) to support patients' decisions.

Decision talk. This talk supports patients' decisions based on their preferences or values. In this phase, "preferences elicit a preference, moving to a decision, and offer review" (Elwyn et al., 2012, p. 1364). During decision talk, patients can decide whether to be screened by examining the risks and benefits. Nurse practitioners can support patients' decisions based on their choices, values, preferences, and options for prostate cancer screening.


Screening for prostate cancer is controversial, and its benefits may be uncertain and small (Hayes & Barry, 2014). Patients thus should be involved in planning their care, starting with deciding whether to be screened. Patients need to be well informed about their risk factors related to prostate cancer, available screening methods, and associated risks and benefits of screening. Practitioners should provide decision aids to help patients make informed, shared decisions about screening. The Shared Decision-Making Model (Elwyn et al., 2012) can be used to guide clinical practice, promote safety, and focus on quality care.


Alberts, A.R., Schoots, I.G., & Roobol, M.J. (2015). Prostate-specific antigen-based prostate cancer screening: Past and future. International Journal of Urology, 22(6), 524-532.

American Cancer Society (ACS). (2017a). Prostate cancer. Retrieved from

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American Cancer Society (ACS). (2017c). Testing for prostate cancer. Retrieved from https :// cancer-org/cancer-control/en/bookletsflyers/testing-for-prostate-cancer- handout.pdf

American Urological Association (AUA). (2013). Early detection of prostate cancer. Retrieved from https://www.auanet. org/guidelines/early-detection-ofprostate-cancer-(2013-reviewed-andvalidity- confirmed-2015)

Carter, H.B., Albertsen, P.C., Barry, M.J., Etzioni, R., Freedland, S.J., Greene, K.L., ... Penson, D.F. (2013). Early detection of prostate cancer: AUA guideline. The Journal of Urology, 190(2), 419-426.

Cuypers, M., Lamers, R.E., Kil, P.J., van de Poll-Franse, L.V., & de Vries, M. (2015). Impact of a web-based treatment decision aid for early-stage prostate cancer on shared decision-making and health outcomes: Study protocol for a randomized controlled trial. Trials, 16(1), 1.

Cuzick, J., Thorat, M.A., Andriole, G., Brawley, O.W., Brown, P.H., Culig, Z. & Ilic, D. (2014). Prevention and early detection of prostate cancer. The Lancet Oncology, 15(11), e484-e492.

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Etzioni, R., Gulati, R., Mallinger, L., & Mandelblatt, J. (2013). Influence of study features and methods on over diagnosis: Estimates in breast and prostate cancer screening. Annals of Internal Medicine, 158(11), 831-838.

Gabrani, J., Knibb, W., Petrela, E., Hoxha, A., & Gabrani, A. (2016). Provider perspectives on safety in primary care in Albania. Journal of Nursing Scholarship, 48(6), 552-560. doi:10.1111/jnu.12236

Hayes, J.H., & Barry, M.J. (2014). Screening for prostate cancer with the prostate-specific antigen test: A review of current evidence. JAMA, 311(11), 1143-1149. doi:10.1001/jama.2014.2085

Kim, E.H., & Andriole, G.L. (2015). Prostate-specific antigen-based screening: Controversy and guidelines. BMC Medicine, 13, 61.

Livingston, C.J., Freeman, R.J., Mohammad, A. , Costales, V.C., Titus, T.M., Harvey, B. J., & Sherin, K.M. (2016). Choosing Wisely[R] in preventive medicine: The American College of Preventive Medicine's top 5 lists of recommendations. American Journal of Preventive Medicine, 51(1), 141-149. doi: 10.1016/ j.amepre.2016.03.009

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Shen, M.J., Nelson, C.J., Peters, E., Slovin, S.F., Hall, S.J., Hall, M., & Diefenbach, M.A. (2015). Decision-making processes among prostate cancer survivors with rising PSA levels: Results from a qualitative analysis. Medical Decision Making, 35(4), 477-486.

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Zheng, K., Dou, Y, He, L., Li, H., Zhang, Z., Chen, Y, ... Kong, L. (2015). Improved sensitivity and specificity for prostate cancer diagnosis based on the urine PCA3/PSA ratio acquired by sequence-specific RNA capture. Oncology Reports, 34(5), 2439-2444. doi:10.3892/or.2015. 4266

Myriam Jean Cadet, PhD, APRN, FNP-C, is Adjunct Faculty, Lehman College, Bronx. NY.
Shared Decision-Making Model

                                       Key to the Figure

Deliberation            A process through which patients become aware
                        of choice, understand their options, and have
                        the time and support to consider "what matters
                        most to them;" may require more than one
                        clinical contact not necessarily face-to-face
                        and may include the use of decision support
                        and discussions with others.

Choice Talk             Conveys awareness that a choice
                        exists--initiated by either a patient or a
                        clinician; may occur before the clinical

Option Talk             Patients are informed about treatment options
                        in more detail.

Decision Talk           Patients are supported to explore "what
                        matters most to them," becoming informed.

Decision Support        Decision support designed in two formats: (1)
                        brief enough to be used by clinician and
                        patient together, and (2) more extensive,
                        designed to be used by patients either before
                        or after clinical encounters (paper, DVD,

Initial Preferences     Awareness of options leads to the development
                        of initial preferences, based on existing
                        knowledge. The goal is to arrive at informed

Informed Preferences    Personal preferences based on "what matters
                        most to patients," predicated on an
                        understanding of the most relevant benefits
                        and harms.

Source: Elwyn et al., 2012.
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Title Annotation:Clinical Practice
Author:Cadet, Myriam Jean
Publication:MedSurg Nursing
Date:Sep 1, 2018
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