A patient-centric approach to the discussion about testing for prostate cancer risk

There is no consensus about the appropriateness of widespread testing for risk of prostate cancer. While many guidelines recommend that primary care physicians have a structured conversation with their male patients about the appropriateness of such testing, we had not (before today) come across any sound guidance for the primary care community about how to have that discussion.

Gaster et al. have attempted to address this serious deficiency in a recent article in the Annals of Internal Medicine, by using what they describe as the “Ask–Tell–Ask” model. At the heart of the approach they describe is the idea of customizing the conversation to the needs of the patient — a “patient-centric” approach — which should bring joy to the heart of the most ardent patient advocate, regardless of individual opinions about the value of mass, population-based screening for prostate cancer.

Gaster and his colleagues — who are all primary care physicians and bioethicists, not urologists or other prostate cancer specialists — make an number of key points in describing their “Ask–Tell–Ask” model:

  • It has been specifically structured to facilitate communication when patients are faced with a decision for which there is no “right” answer.
  • It focuses on the communication process as opposed to the body of information to be shared with the patient.
  • It prioritizes the need to tailor the conversation to the individual patient’s desired level of involvement.
  • It seeks to initiate the conversation by establishing “where the patient stands” in his personal decision-making process.
  • It emphasizes the importance of a shared decision based on the patient’s perceptions.

In other words, rather than seeking to “educate” the patient, Gaster et al. describe a process through which doctor and patient can — relatively quickly — come to a mutual understanding about the patient’s level of knowledge, the patient’s personal goals, and an appropriate way to move forward. It has also not escaped our notice that this approach does not even address the much-raised issue of “over-diagnosis” so mistrusted by many prostate cancer patient advocates.

The actual model for the conversation is broken down into three sections, as follows:

  • An initial “Ask” phase, in which the doctor’s responsibilities are
    • To explore the patient’s baseline knowledge.
    • To elicit  and understand the patient’s values and preferences.
  • A follow-up “Tell” phase, in which the doctor should
    • Invite the patient to participate in making the decision.
    • Provide unbiased information to fill gaps in understanding.
    • Suggest ways other men have dealt with this choice.
    • Offer support, regardless of what decision the patient makes.
  • A wrap-up “Ask” phase, during which the doctor confirms that the patient’s needs have been met and inquires whether he is ready to make a decision by
    • Clarifying the patient’s values and preferences.
    • Confirming that the decision fits the patient’s values.
    • Confirming the proposed plan or negotiating an alternative one.

The full text of the paper offers examples of specific questions, ways in which to address concerns, how patients’ personal experiences and knowledge are highly relevant to their decision processes, etc. The critical factor, however, is the way in which the patient is placed at the center of the discussion throughout. The personal opinions of the physician are subjugated to the knowledge and needs of the patient.

We should be clear that we can imagine some problem areas even with an approach like this. At an extreme end, for example, what should the doctor “Tell” a 90-year-old male patient with a history of cardiovascular problems who is insisting on  getting a PSA test? However, …

This paper by Gaster and his colleagues should (in our very humble opinion) be required reading for every primary care physician in the U.S. today. It is one of the best descriptions we have ever seen of how a primary care provider should approach such a complex issue as the appropriateness of prostate cancer risk monitoring for the individual patient. It may not be perfect, but it is an outstanding model for patient-centric, participatory medicine that gives full recognition to the importance of the patient’s knowledge and perspectives.

If you run a prostate cancer support group, get a copy of this paper, and share it as widely as you can manage!

It is only appropriate to conclude this commentary with the final paragraph from the paper itself:

Although no approach will make prostate cancer screening discussions easy, the Ask–Tell–Ask approach is designed to be time efficient, process oriented, and patient centered, with the goal of improving the quality of care by encouraging more informed decisions about prostate cancer screening.

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