There are no recent guidelines regarding the use of PSA tests and digital rectal exams as tests for risk of prostate cancer issued by any of the national organizations representing primary care physicians. However, a new report has provided data about the current behaviors of members of the primary care community at one academic medical center.
Tasian et al. mailed a self-administered questionnaire to all primary care physicians at this academic medical center. The questionnaire was designed to assess the providers’ knowledge of prostate cancer, their confidence in their knowledge, and their PSA screening/testing practices.
The results reported by the authors are as follows:
- 82 physicians (30.4 percent of those mailed) completed the survey.
- 80/82 responders (98 percent) correctly identified African-American race as a prostate cancer risk factor.
- 34/82 responders (42 percent) correctly identified digital rectal exam and PSA as the accepted methods of testing for risk of prostate cancer.
- 48/82 responders (59 percent) underestimated the likelihood of prostate cancer in a man with a PSA level > 4 ng/ml.
- Only 16/82 responders (19 percent) described themselves as “confident” in their knowledge of prostate cancer.
- 71/82 responders (86 percent) tested < 60 percent of their male patients over 50 years of age.
- A knowledge score above the average was not associated with any increase in likelihood to test patients for their risk of prostate cancer.
- Confidence in the provider’s knowledge was associated with ordering PSA tests.
- Physician- and patient-related factors (e.g., a physician’s ethnicity or a patient’s request for a PSA test), as well as practice guidelines, particularly those of the US Preventive Services Task Force, influenced providers’ decisions to offer PSA testing.
It has been well understood for some time that there is confusion among men in general and among members of the primary care community about appropriate use of PSA testing. These data would clearly support the desperate need for some clear and simple guidance about the appropriate use of PSA testing and the DRE for primary care providers. If organizations like the American Cancer Society and the American Urological Association are going to issue guidance that all men have a discussion with their doctors about the appropriateness of PSA testing for them as individuals, based on their personal risk factors and other considerations, then it is critically important for the primary care community to have a shared understanding of the level of utility and value of these tests in men aged (at a minimum) between 40 and 75 years of age.
The authors conclude (politely in our estimation) that, “Respondents correctly identified prostate cancer risk factors but were less knowledgeable about prostate cancer screening tests and overall prostate cancer risk. Most respondents were not confident in their knowledge and did not screen men over 50.” Of course a similar questionnaire might indicate that members of the primary care community were also under-informed about issues related to testing for risks for breast, colon, and cervical cancers — but we hope not!
Filed under: Diagnosis, Risk | Tagged: knowledge, primary care, prostate specific antigen, PSA, risk, screening, testing |
THE "NEW" PROSTATE CANCER INFOLINK 
Surely a partial solution to the ignorance expressed by this sample of primary care physicians regarding prostate cancer should be routine updates available on a daily basis through news briefs. To be a busy practitioner does not excuse well-meaning doctors from getting current research on a weekly if not daily basis. Primary care physicians simply must get more up-to-date in pursuing the knowledge readily available to them if they only look for it. I have a hunch that the pursuit of knowledge is less a matter of doctors’ limited time and more a function of whether they understand that continuing education is the foundation of any good medical practice.
This study provides an illustration of the need to recommend prostate cancer screening using PSA. I recently participated in a symposium on PSA screening and one of the panelists correctly suggested that any discussion between a doctor and his patient should FOLLOW the PSA test and not come prior to it. His reason for that was the PCPs are overworked and it doesn’t make sense to have them have a long discussion on treatment and side effects for a disease that may not occur at all. The study described in this post presents another reason: PCPs are not sufficiently educated on the topic and will probably have some difficulty carrying on this conversation.
One of the problems of being a primary care physician is just how much one has to try to “keep up” with. I don’t happen to believe it is reasonable to expect a primary care doctor to be able to keep up with current research on prostate cancer. It is just one of hundreds of equally prevalent and more common disorders that a primary care physician might come across on a daily basis.
However, it is (at least in my view) sad that neither the American Assoication of Family Physicians nor the American College of Physicians (the two largest primary care medical societies) offer any clear and current guidance on the appropriate monitoring of risk for prostate cancer to their members. Men with clear risk factors should either be talking to a primary care physician who does understand how to assess that risk or the primary care physician should be referring appropriate patients to a specialist who can assess that risk.
I made very sure some years ago that my primary care physician and I had a shared understanding of our viewpoints on cancer risk among males and how those should be appropriately monitored. I considered that to be my responsibility … Of course I then had an unexpected heart attack!