[Background music]
[Words on screen] Shared Decision Making in Prostate Cancer Screening
[Words on screen] A Conversation with a Patient at High Risk
[Doctor speaking] Okay, before we wrap up today, I'd like to talk to you about prostate cancer. You may know that African Americans and other black men are at a higher risk for prostate cancer than white men. And the risk increases starting at age 40. So, to give you an idea, about one in five black men will be diagnosed with prostate cancer in their lifetime. For one in 22 black men, it will be the cause of their death.
[Patient speaking] My grandfather had prostate cancer so, it runs in my family, too.
[Doctor speaking] Your family history probably puts you at somewhat higher risk, but not as high as it would be if you had a brother or a father with prostate cancer. Here's the thing-- doctors don't all agree about testing. 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 some 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. And we don't have to come to a decision today.
[Words on screen] Invite your patient in the conversation.
[Patient speaking] Okay.
[Doctor speaking] So 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] So what would happen if the biopsy showed cancer? I would have surgery to remove it, right?
[Doctor speaking] I wish there was an easy answer to that, but not all prostate cancer is harmful. The action we take would depend on how likely it is that the cancer we found will cause harm.
[Patient speaking] But I thought all cancer was dangerous and could spread.
[Doctor speaking] Well, unlike a lot of other types of cancer, 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 treatment be?
[Words on the screen] Present all available options, and the benefits and risks.
[Doctor speaking] Well, treatment is usually surgery, radiation, or both. There are side effects, like urine leakage. 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 these?
[Patient speaking] I don't think those side effects are as bad as living with cancer. I'd want to get treated and not have cancer in me.
[Doctor speaking] Okay. That's good for me to know. 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] 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 the cancer is growing. At that point it may be too late for prostate surgery or radiation to cure the cancer. So, what do you think about this--the active surveillance route? I know you said earlier that you wouldn't want cancer inside of you.
[Words on screen] Learn about your patient’s values and concerns.
[Patient speaking] Yeah, I don't think I'd want to wait to do something if I knew there could be harmful cancer inside of me.
[Doctor speaking] Okay. Remember to keep in mind that just because you have a risk factor doesn't mean that we would definitely find harmful prostate cancer. For every man who's been diagnosed by a PSA test and is cured, 20 or more will have a prostate cancer diagnosed and will not benefit from treatment, usually because the cancer isn't harmful. It's important for you to know before you do the test that if we did find cancer, and I was confident that it wasn't harmful, I may recommend active surveillance. So, does that make sense?
[Patient speaking] Yeah, I see what you're saying. You want to be sure I understand what could come down the line before I decide about the test.
[Doctor speaking] Right. But for now, the first thing to consider is the test. Then there may be decisions after the test, like we've talked about, so it's good for you to 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 how you're feeling about getting the PSA test.
[Patient speaking] I think I should probably get the test, especially since the prostate cancer's been in my family. But I'm not sure about the active surveillance that you explained, and whether I'd be okay with that. Would you recommend I get the test?
[Words on screen] Facilitate your patient’s decision making.
[Doctor speaking] I recommend patients do the test only if they're really sure it's right for them. For today, I suggest you take this information with you. It has answers to common questions 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