[Background music playing]
[Words on screen] Shared Decision Making in Prostate Cancer Screening
[Words on screen] A Conversation with a Patient at Average Risk
[Doctor speaking] So, you were given a decision aid sheet about prostate cancer screening when you checked in today. Did you get a chance to review that?
[Patient speaking] Oh, yeah. I mean, I read it in the waiting room. No one in my family's had prostate cancer, so, I mean, should I even be worried about it?
[Doctor speaking] Well, about one in seven men like you, who are at average risk, will at some point be diagnosed with prostate cancer. It's the most common major cancer in men. Also, the risk goes up for men over 50. For about one in 38 men, prostate cancer will be the cause of their death.
[Patient speaking] Okay. Good to know. I've heard that doctors disagree about testing for prostate cancer, though. What do you think about it?
[Doctor speaking] Well, there are pros and cons to the test. Getting tested every one to two years could reduce your risk of dying from prostate cancer by 20% to 30%. But the test can also lead to harm. For some men, not getting tested and avoiding the harm is the right choice, even though they lose a small benefit. It's complicated, so let's talk it through. We don't have to come to a decision today.
[Words on screen] Invite your patient in the conversation.
[Patient speaking] Okay.
[Doctor speaking] PSA stands for prostate specific antigen. The test for prostate cancer is a blood test that measures your PSA level. A high PSA level might mean prostate cancer, but it could also mean things that aren't cancer, like an enlarged prostate. Does this make sense so far?
[Words on screen] Check for understanding from your patient.
[Patient speaking] Yeah, I think so.
[Doctor speaking] Because we don't know for sure what's causing a high PSA level, we'd do more tests to find out. If more tests showed that the likelihood of prostate cancer was high enough, then I might recommend a prostate biopsy.
[Patient speaking] Okay. And if you found cancer, then I'd get treatment, right?
[Doctor speaking] Unfortunately, that's not an easy answer. The action we'd take would depend on how likely it is that the cancer we found will cause harm. Not all prostate cancer is dangerous.
[Patient speaking] But I thought all cancer was dangerous and could spread.
[Doctor speaking] Well, unlike a lot of other types of cancers, most prostate cancers grow very slowly and won't cause problems or need treatment, so treating these cancers could do more harm than good. But harmful cancers can spread, and treatment is needed to stop them. The tough part is that we can't always tell which cancers are harmful and which ones would grow slowly and never need treatment.
[Patient speaking] If you did find the harmful kind, what would the treatment be?
[Words on the screen] Present all available options, and the benefits and risks.
[Doctor speaking] Treatment is usually surgery, radiation, or both. There are side effects, like urine leakage. And some men also experience impotence--they can no longer get an erection. Blood clots and heart attacks are much less common, but those are possibilities following any major surgery. So, what do you think about that?
[Patient speaking] Those are some serious side effects, I would definitely like to avoid.
[Doctor speaking] Well, if I was confident that a cancer was most likely harmful, I'd recommend treatment in most cases. But if the cancer didn't appear to be harmful, there would be another option called active surveillance. Choosing this option could mean that you'd avoid the possible side effects of treatment.
[Patient speaking] Can you explain that option?
[Doctor speaking] Sure. We would keep a close eye on your prostate for a long time, by doing a PSA test every few months and repeating the biopsy from time to time--maybe even doing an MRI of the prostate, too. If the cancer grows, we'd reconsider treatment.
[Patient speaking] That sounds okay. But is active surveillance safe?
[Doctor speaking] We're still studying it, and there's a lot we don't know for sure. There's some risk with active surveillance that cancer cells could spread before we see that the cancer is growing. At that point it might be too late for prostate surgery or radiation to cure the cancer. So, what do you think about this--the active surveillance option?
[Words on screen] Learn about your patient’s values and concerns.
[Patient speaking] Well, I know I wouldn't want treatment unless you were sure I needed it. If you found something and you were pretty sure it wasn't harmful, why get treatment that could cause those side effects? With active surveillance, you'd just watch it closely, right?
[Doctor speaking] That's right. It sounds like active surveillance is something you'd consider. That option is important for men to understand before they decide to get a PSA test.
[Patient speaking] So the first decision is the test?
[Doctor speaking] Right. Then there may be decisions after the test, like we've talked about, so it's important that you know about these things as you consider what's right for you. You don't have to make a decision right now, but I'd like to know about your feelings about getting the PSA test.
[Patient speaking] I'm leaning toward getting it. But I'm worried about winding up with side effects from treatment that doesn't end up benefiting me. Do you recommend I get tested today?
[Words on screen] Facilitate your patient’s decision making.
[Doctor speaking] No, no-- I recommend patients do the test only if they're really sure it's right for them. So, for today, I suggest you take this information sheet with you-- it has answers to common questions that men have. We can talk about it more when I see you in a couple of months.
[Patient speaking] Thanks. I'll take a look and talk about it with my family, too.
[Doctor speaking] That sounds good.
[Words on screen, music playing] Shared Decision Making in Prostate Cancer Screening
[Checklist of items] Invite your patient in the conversation.
Check for understanding from your patient.
Present all available options, and the benefits and risks.
Learn about your patient’s values and concerns.
Facilitate your patient’s decision making.
[Words on screen] Learn more at www.mass.gov/dph/cancerscreenings
Massachusetts Department of Public Health