Changing physicians’ behaviors (about PSA testing)

It is common for patients to suggest that primary care physicians should be more knowledgeable about the appropriate use of PSA testing and about how to interpret the results of such tests. However, changing physician behavior is not an easy or a quick process, as the following article will demonstrate.

Kerfoot et al. thought that they could use a targeted, e-mail-based intervention process, which they refer to as “spaced education,” to reduce the inappropriate use of PSA testing for risk of prostate cancer in men under 40 years of age and over 76 years of age. (To be clear, there are obviously some appropriate young and old candidates for such testing but, in general, the widespread use of PSA “screening” of men under 40 or over 76 is not recommended by any set of clinical guidelines.)

To test this hypothesis, Kerfoot et al. carried out a randomized controlled trial among 95 primary care physicians practicing at  eight Veterans Affairs medical centers between January 2007 and February 2009. The physicians were divided into two groups:

  • Group A comprised the “spaced education” group, who received nine educational e-mails in four cycles over a period of 36 weeks.
  • Group B comprised a control group who received no specific educational intervention.

For the physicians in Group A, each e-mail gave a clinical case scenario and then asked whether it was appropriate to obtain a PSA test. The participants were given immediate feedback after submitting their answers.

The primary outcome of the study was the number and percentage of PSA tests actually being ordered by the participants in their day-to-day clinical practice for real patients who met the predetermined criteria for inappropriateness (as defined above). Patients who were getting PSA tests for other reasons than just testing  for prostate cancer risk (e.g., because the patient had problems urinating) were excluded using a structured and validated protocol.

Here are the results of the study:

  • During the actual intervention period (weeks 1-36), clinicians in Group A ordered significantly fewer inappropriate PSA tests than clinicians in Group B  (10.5 vs 14.2 percent, respectively).
  • During the 72-week period after the intervention (weeks 37-108), clinicians in Group A continued to order significantly fewer inappropriate PSA tests than clinicians in Group B (7.8 vs 13.1 percent, respectively).
  • The reduction in inappropriate PSA testing during the 72-week follow-up period represents a 40 percent relative reduction in inappropriate use of PSA testing to screen for prostate cancer risk.

Kerfoot and his colleagues conclude, correctly, that, “Spaced education durably improves the prostate cancer screening behaviors of clinicians and represents a promising new methodology to improve patient care across healthcare systems.”

However, it is also worth noting that among the primary care doctors in Group B, who received no targeted education at all, over 85 percent were using PSA testing appropriately to test for risk of prostate cancer (within the limits of the study protocol), and that the absolute impact of the educational initiative was only to reduce use of “inappropriate” PSA testing by about 5 percent. If we can only accomplish a 5 percent change in physician behavior using such an intensive educational method, this gives readers some idea of the problem of changing physician behavior.

There are a thousand reasons why changing the behaviors of highly educated adults can be difficult. Actually this is true in almost every profession. And it is just as true of patients as it is of their doctors.  Millions of patients know that they should eat less (or just better), exercise more, stop smoking, not drink and drive, you name it — but we go on doing what we have always done anyway. It is easy to say that the primary care docs should know more about PSA testing and carry it out more appropriately. Getting them to actually do that … and to interpret the resulting data with greater sophistication (which Kerfoot et al. didn’t even try to address) is a more challenging opportunity!

10 Responses

  1. Wonder if it would work in reverse? Could they get a doctor to order more PSAs or some other test on appropriate men? Also wonder if their experience changes the way they react. If they have previously found an aggressive prostate cancer in this group of men, are they more likely to order the test? Does personal prostate cancer history in their family may make them more likely to order the test?

    So many variables. The unknowns and controversy about early detection is confusing. I get questions from nurses and health educators all the time. They do not know what the issues are nor do they often talk to many survivors. Seems that many of them have the papers but very little exposure to conversation. Some of them have never really learned to talk to men very effectively, they come once to programs but never come back. We are sorely lacking in men’s health education and conversation in the primary care realm. Would love to see surveillance studied this way rather than early detection. One prostate cancer navigator told me last week that she would not recommend AS to any patient because the evidence was not there and it could mean his death. When I asked if she would recommend a clinical trial of active surveillance to a man she said no and walked away. Another general navigator overheard us and wanted more information about active surveillance and how to find a trial. Prostate cancer is such a murky area. If these women who specialized in cancer were so far apart and wanting information then I wonder what happens in the mind of a primary care MD?

  2. I would suggest reading the European Urologist Association (EUA) guidelines on prostate cancer. It has a detailed chapter on AS and WW (watchful waiting).

    The discussion on PSA screening is usually lacking in not discriminating on the basis of life expectancy — health and age. The Goteborg study demonstrates unequivocally the life-saving results of PSA testing for young, healthy men who have a good life expectancy.

    The common argument against PSA testing is that it detects many cases of slow-growing, indolent cancer, but this is mostly the case for older men.

  3. Not sure what a “cancer navigator” is, but it must be a “profession” that doesn’t subscribe to a code of ethics, nor any form of ongoing professional development. How could there be any profession that counsels patients on treatment options without providing the pros/cons of all available treatments and without requiring awareness of, not just experimental, but common forms of standard treatment?

    Next time you see the “navigator” who has taken it upon herself to cut her clients off from navigating half the prostate cancer universe, you might suggest to her that she study up a little on the concept of “over-treatment” and try to wrap her blindered little brain around the fact that the industry itself admits to being unable to distinguish indolent from aggressive disease, implicitly admitting to subjecting thousands and thousands of men to permanently disabling side effects for no medical reason. Makes you wonder what choices exactly the first navigator offers to men, “You can drive off a cliff or into a brick wall?”

    Is there a licensing body (at the local, state, national/international level) for “cancer navigators” (are they nurses, perhaps)? If so, I would treat both of these women’s responses as gross negligence and incompetence and turn them over to their licensing agency. Their ignorance of accepted treatments and unwillingness to acknowledge the risks inherent to all current, standard treatment modalities except AS makes them very dangerous “navigators” indeed.

  4. The navigator is doing what she believes is the best for the men. She is advising them based on the information in the NCCN guidelines and I cannot fault her for that. She said she is getting mostly men whose cancer is too aggressive or who are too young, under 65. That was when I suggested clinical trials. Her not being open to trials is what bothered me the most. If we can’t get men more involved in trials, we will never be able to overcome these obstacles.

  5. The idea of purposely withholding information about AS from men younger than 65 is particularly cruel.

  6. I hope you will share with this woman who has decided to insert her personal values into determining the quality of life for every couple under 65 who has had a prostate cancer diagnosis of the recommendation from the new European guidelines on clinically localized prostate cancer:

    * Active surveillance is a viable method of management for men with low-risk prostate cancer and a long life expectancy.

    Note to self: Avoid PCa ‘navigators’ at all costs.

  7. According to the patient section of the NCCN guidelines, AS is a reasonable and recommended treatment strategy.

    So, I don’t know what she’s using to rationalize her decision to withhold information about the only currently available treatment protocol that doesn’t involve a risk of 50 percent or higher of serious, permanent quality of life reduction, but that’s not what the NCCN recommends.

  8. Dear Tracy:

    This is one of the problems of reading only the patient guidelines. The physician guidelines issued by NCCN include great deal more specificity about the appropriateness of AS in the areas of life expectancy, low- and very low-risk patient categories, etc. Just as an example, they would not recommend AS exclusively for a low-risk patient (as opposed to a very low-risk patient) with a life expectancy in excess of 10 years. In that case it is just one of several possible treatment options. By comparison, for very low-risk patients, active surveillance is the only recommended treatment option for men with a life expectancy of up to 20 years (effectively, any otherwise healthy man of 60 or older).

  9. Dear Mike,

    That doesn’t really make me feel any better. Why would any information about treatment protocols be hidden from patients? There’s got to be some way to buy time for men who want to be both sufficiently vigilant to protect their lives through competent professional management of the progress of their disease and yet still choose a reasonable quality of life by avoiding taking the very, very high risk of diminished quality of life endemic to the radical treatments currently available.

    The most depressing part about hearing of this prostate cancer “navigator”‘s practice of withholding information from her patients is that there’s no one to trust in the process.

  10. Tracy:

    It wasn’t meant to make you “feel better.” The truth is that, in the real world, just as when he (or she) takes his (or her) car to a mechanic, every patient needs to become his (or her) own advocate. Medicine worked much better in terms of the doctor-patient relationship when there were a limited number of things that physicans could do for a sick patient. Of course most of those options didn’t work very well, so the chances of effective treatment were poor, but it was easier for the doctor to be completely honest, and there were fewer things for the patient to worry about.

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