UROLOGICAL ONCOLOGY In the Era of Shared Decision Making, How Would An Iranian Urologist Screen Himself For Prostate Cancer? Majid Ali Asgari, Mohammad Soleimani,* Farid Dadkhah, Alireza Lashay, Erfan Amini, Maryam Baikpour, Razie Amraei Purpose: Prostate cancer (PCa) poses a significant health problem in developed countries. Prostate specific anti- gen (PSA) based screening for PCa is controversial and large trials have failed to show a significant reduction in prostate-specific mortality and all-cause mortality. Considering the contradictory data on PCa screening, current guidelines emphasize shared decision making. Physicians are the ones in charge of helping patients with informed decision making, so we conducted this study to find out what urologists would do for themselves as patients. Materials and Methods: Urologists attending the 15th congress of Iranian Urological Association were invited to participate in a questionnaire-based survey on PCa screening. A total of 184 physicians completed the question- naire. Results: Of participants 76.8% declared that they would like to be screened. 69.3% of those in favor of screening did not consider digital rectal examination (DRE) as part of their screening program. 62.8% of the urologists will- ing to be screened chose serial PSA as their follow up method in case their PSA level came above normal ranges, and 35.8% preferred to be biopsied. Conclusion: Urologists tend to prefer PSA screening despite the current controversy about its usefulness. Most of the urologists practicing in Iran do not choose DRE as part of their screening program. Large high quality studies conducted in other countries are needed to look into urologist’s attitudes towards PCa screening, and to investigate their preferences in order to understand the rationale behind their decisions. Keywords: practice guidelines as topic; prostate; prostate-specific antigen; prostatic neoplasms; diagnosis; health knowledge; attitudes; practice. INTRODUCTION Prostate cancer (PCa) is the most frequently diag-nosed cancer and a major cause of death among men in developed countries.(1,2) Although the majori- ty of men older than 50 years in these countries have been screened for PCa with the prostate-specific anti- gen (PSA) blood test,(3,4) PCa screening is controversial because there is no convincing evidence that screening reduces disease-specific morbidity and mortality. The European Randomized Study of Screening for Prostate Cancer (ERSPC) showed an absolute reduc- tion of 0.09% in PCa deaths in men aged 55 to 70 after 11 years of follow up, suggesting a negligible survival benefit for screening.(5) Meanwhile, the simultaneous- ly published results from the American Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening Trial found a slightly increased risk of PCa mortality in screened men after 13 years, which was reported to be statistically insignificant.(6) Both PLCO and ERSPC failed to demonstrate a reduction in all-cause mortality perhaps due to the fact that most men with PCa die of competing causes in this age group. There are considerable data suggesting that treatments for early stage cancers- the targets for screening-may lead to important complications(7) and are only margin- ally beneficial, especially for men 65 years and older.(8) The recommendations of available guidelines on PCa screening vary as a result of the emerging new evidence. Some guidelines, namely the 2012 US Preventive Ser- vices Task Force (USPSTF), are now recommending against PSA based screening,(9-11) while others still ad- vocate its use in men with a life expectancy of greater than 10 years.(12-14) Considering these contradictory data about PCa screening, most professional organizations recommend that the first step in screening should be a discussion between health care providers (HCPs) and patients about the potential harms and benefits of early detection and treatment to help patients make informed Department of Urology, Clinical Research Development Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran. *Correspondence: Department of Urology, Clinical Research Development Center, Shahid Modarres Hospital, Shahid Be- heshti University of Medical Science, Tehran, Iran. Tel: +98 9125954970. Fax: +98 21 22074101. E-mail: mohamad.soleimani.md@gmail.com. Received January 2015 & Accepted October 2015 Vol 12 No 06 November-December 2015 2404 decisions regarding PCa screening.(15) Unfortunately unlike many other preventive servic- es, discussion about PCa screening is relatively com- plicated and not all the necessary information can be conveyed to the patient in a single office visit.(16) Also, lack of patient health literacy is an important barrier to shared decision making.(17) Consequently, true in- formed decision making about PSA testing rarely oc- curs in practice.(18) An ideal thoroughly-informed patient is the one that has as much knowledge on the subject as a physician. In other words, doctors can be considered as fully in- formed patients. Among the health care providers who are responsible for informing patients about risks and benefits of PCa screening and treatment, urologists are the ones with the most accurate knowledge on this sub- ject. So we decided to conduct a survey among urol- ogists to discover what they would choose for them- selves as patients. MATERIALS AND METHODS In April 2012, through a convenience non-random sam- pling method, board certified urologists attending the 15th congress of Iranian Urological Association, were invited to participate in a questionnaire-based survey on PCa screening. Participants were asked to answer questions on what screening methods and treatment measures they would choose for themselves. 184 phy- sicians were willing to participate and completed the questionnaire. There were missing data on some of the questions (Ta- ble1); for every question only the valid data were in- cluded, but the missing data would comprise the sample for the remainder of the questions. Data analysis was performed using the Statistical Pack- age for the Social Science (SPSS Inc, Chicago, Illi- nois, USA) version 19.0. Descriptive statistics of the variables were calculated. To evaluate the correlations between variables, Chi-Square test and independent samples t-test were used for qualitative and quantita- tive variables respectively. ANOVA test, Spearman and Kendall’s tau Correlations were also utilized as needed. RESULTS The mean age of the participants was 46.3 ± 9.08 years with the minimum and maximum being 30 and 65 years respectively (Figure 1). Of participants 100 (69%) were under the age of 50, and 45 (31%) were over fifty years old. 36 questionnaires lacked information on age of the participant. The mean value of years of experience was 12.37 ± 8.19 years, with a minimum of zero and a maximum of 31 years. Fifty-nine (33.5%) responders were attend- ing-urologists in academic centers, 69 (39.2%) pro- vided health care services in public hospitals, and 48 (27.3%) were in private practice. Urologists' Attitude towards Prostate Cancer Screening-Asgari et al. Table 1. Valid and missing data regarding each question. Variables Age Graduation Year Type of Fellowship Fellowship Previous Plan of Method of Follow up (years of experience) Medical Course Screening Screening Screening Methods Practice Valid 145 165 176 176 169 181 181 179 177 Missing 36 16 5 5 12 0 0 2 4 Variables Age (years) P Value Years of P Value Type of P Value mean ± SD Experience Medical Practice Academic Public Private No. % No. % No. % Plan of screening Yes 46.63 ± 9.14 .449 12.72 ± 8.00 .333 43 72.9 54 78.3 38 79.2 .695 No 45.29 ± 8.94 11.28 ± 8.78 16 27.1 15 21.7 10 20.8 Method of screening PSA and DRE 43.72 ± 8.43 .052 11.03 ± 7.56 .136 12 28.6 20 37.0 8 21.6 .280 PSA alone 47.58 ± 9.25 13.37 ± 8.11 30 71.4 34 63.0 29 78.4 Follow up methods Biopsy 45.03 ± 9.51 .478 10.48 ± 7.58 .081 18 45.0 20 36.4 10 26.3 .318 Serial PSA 46.70 ± 8.76 13.42 ± 7.69 21 52.5 35 63.6 27 71.1 No Follow up 42.00 ± .00 9.00 ± 2.83 1 2.5 0 .0 1 2.6 Abbreviations: SD, standard deviation; PSA, prostate specific antigen, DRE, digital rectal examination. Table 2. Correlations between all the evaluated variables. Urological Oncology 2405 With regard to training, 53 (30.1%) participants had completed fellowship training in urology subspe- cialties: 25 in endourology, 5 in urologic-oncology, 15 in transplant, and 1 in reconstructive urology (7 respondents didn't specify their fellowship field). One hundred twenty-three (69.9%) of the urologists didn't have a fellowship degree. Previous Screening Seventy one (39.2%) of the respondents stated that they had undergone previous PSA screening, 12 of whom were less than 50 years old. Among urologists over the age of fifty 84.4% had undergone previous PSA screen- ing. Plan of Screening When asked whether they had a plan of screening for themselves, 139 (76.8%) urologists answered yes. For- ty-two (23.2%) preferred not to undergo screening for PCa. Among the 71 urologists who had undergone pre- vious PSA screening, 9 (12.6%) mentioned no further plans for PCa screening. The mean age of the participants with a positive answer to this question was slightly higher than the subjects who declared no plans for screening (46.63 ± 9.14 years vs. 45.29 ± 8.94 years), but the differences were not statistically significant (P = .449). Similarly, the av- erage years of experience was also higher in the first group (12.72 ± 8.00 years vs. 11.28 ± 8.77 years) but the differences were not found to be significant with a P = .333 (Table 2). Surprisingly the lowest percentage of positive answers to this question was found among the urologists working in academic centers with 72.9%. Following that, 78.3% of the subjects in public practice and 79.2% of the ones working in private section had claimed to have screening plans. However, the differ- ences were found to be insignificant (P = .695) (Table 2). Method of Screening Of those who had a plan of being screened, 69.3% (n = 95) preferred PSA alone, while 30.7% (n = 42) consid- ered DRE along with PSA as their method of choice. The mean age of the participants who mentioned PSA alone as their preferred screening method was higher than the subjects who chose PSA and DRE togeth- er (47.58 ± 9.25 years vs. 43.72 ± 8.43 years) but the differences were insignificant (P = .052). The average years of experience also followed a similar pattern with 13.37 ± 8.11 years among the ones who chose PSA alone and 11.03 ± 7.56 years in subjects who chose both methods (P = .136) (Table 2). PSA alone was most commonly selected by the urologists working in private section with 78.4%. Participants from academic hospi- tals were in the second place with 71.4% and the low- est percentage was found among the subjects in public practice with 63.0% (P = .280) (Table 2). Follow up Method Urologists that were willing to be screened were asked about their method of choice for follow-up, in case their PSA levels came above normal ranges. 84 (62.2%) chose serial PSAs, 49 (36.3%) preferred to be biopsied, and 2 (1.5%) stated that they wouldn't go through any follow-ups. The mean age of the subjects who chose serial PSA as follow-up method was 46.93 ± 8.78 years. This figure was 45.03 ± 9.50 among the participants who chose biopsy and 42 in the subjects who preferred no fol- low-ups. The differences were evaluated via ANOVA test and were found to be insignificant (P = .478) (Ta- ble 2). Urologists who chose serial PSA as their fol- low-up method of choice had the highest average years Figure 1. Distribution of participant's age. Figure 2. Urologists' preferred follow up method relative to their type of practice. Blue: Prostate biopsy. Green: Serum prostate specific antigen measurement. Urologists' Attitude towards Prostate Cancer Screening-Asgari et al. Vol 12 No 06 November-December 2015 2406 of experience with 13.59 ± 7.72 years. The second highest figure was 10.48 ± 7.57 among subjects who selected biopsy. The mean for the two participants who preferred no follow-ups was 9 ± 2.82 years (P = .081) (Table 2). The highest preference rate for biopsy as the method of choice for follow-up was 46.2% among the subjects working in academic centers compared to 37% in participants from public practice and 26.3% among the ones from private section. On the other hand, 71.1% of the private section urologists selected serial PSA as their method of choice. The differences between follow up methods regarding the participants’ type of medical practice were insignificant (P = .318) (Table 2) (Figure 2). DISCUSSION No matter what the final recommendations of different guidelines on PCa screening are, a general emphasis on shared decision making prevails. To guide patients in their decision, doctors are supposed to provide them with all the available information on screening harms and benefits. But even with the advent of prewritten pamphlets, this concept is practically unachievable in clinical settings. A study by Pollack and colleagues(19) on health care provider's perspective towards discon- tinuing PCa screening, found that the two most impor- tant factors in cessation of PSA screening were patient expectation (74.4%) and time constraints (66.4%). But even if these obstacles were overcome, and informed decision making actually put into practice, physicians will not limit guiding patients to evidence alone. They will share their own perspective with patients and influ- ence their decisions to a great extent. Of course doctors have the added advantage of having experience as well as knowledge, but as a downside, physicians are likely to stick to a previous practice despite strong evidence against it. This will definitely translate into what they will be recommending to patients. So if informed de- cision making happened as completely as theoretically desired, we can expect patients to think like doctors, and to have quite the same attitudes towards screening. Therefore we conducted this survey to find out what urologists or rather "fully-informed patients" would choose to do for themselves (provided that they are aware of almost all the available evidence on harms and benefits of screening). Our study showed that despite the controversy on PSA-based screening,(9-14) most urologists prefer to be screened for PCa. This choice was irrespective of phy- sician's age, years of experience, type of medical prac- tice, and fellowship status, meaning that a great num- ber of urologist with different backgrounds are still in favor of PCa screening. In a recent survey by Pollack and colleagues, health care providers in a university-af- filiated practice (Johns Hopkins Community Physician) who attended an annual organizational retreat were asked about their opinion on latest USPTF draft on PCa screening. 92.7% of the 123 practitioners had heard about the USPSTF recommendations. Approximately 50% of them agreed that the recommendations were ap- propriate, while 36.0% disagreed. Only a few providers (2%) said that they would no longer order routine PSA testing; about 60% said that they would be less like- ly to do so; and 38% said that they would not change their screening practices. Even among those clinicians who agreed with the draft recommendations, fewer than half stated that they would no longer order routine PSA screening or be much less likely to do so.(20) Our study demonstrated that 69.3% of those in favor of screening did not consider DRE as part of their screen- ing program. Physicians 50 years and older were twice more like to refuse DRE compared to those under 50 (P = .06). Even among the five urologic-oncologists who participated in our study, only three chose DRE along with PSA. In their prospective study on 450 men, Romero and colleagues looked into the reasons why pa- tients reject digital rectal examination.(21) According to their results, among the 8.2% who rejected DRE despite an initial educational program on PCa screening and a second consultation to orient participants on the impor- tance of DRE, 84.4% still had misconceptions about screening. 43.7% were concerned about severe discom- fort during the procedure, and 53.1% regarded DRE as a reason for shame. The latter might be even more pro- nounced in some cultures especially those with strict religious beliefs. Conducting similar studies on other populations can show the impact of cultural values on patient's attitudes towards DRE and might stress the significance of developing culture-specific guidelines. Studies show that cancers with higher stages and grades have shorter PSA doubling times.(22) Therefore follow- ing the pattern of PSA increase can be an effective fol- low up method to substitute the more invasive prostate biopsy. Harms of prostate biopsy include persistent hematospermia, hematuria, fever, urinary retention, prostatitis and urosepsis.(23) According to the results of Protect study, about 19.6% of men who undergo biop- sy, consider these as moderate to major problem.(24) Our results show that 62.8% of the urologists willing to be screened chose serial PSA as their follow up method, and 35.8% preferred to be biopsied. Participants who had spent more years in medical practice, were more Urologists' Attitude towards Prostate Cancer Screening-Asgari et al. Urological Oncology 2407 likely to choose serial PSA but the correlation was not statistically significant (P = .42). Compared to faculty members, physicians who were in private practice were 1.5 times more likely to follow an abnormal test result with serial PSA (P = .38). The major limitation of this survey was the method of sampling. Since accessibility to a large number of urologists working in different parts of the country is extensively limited, we decided to conduct this study on a sample of participants gathered from all around the nation for a congress being held in Tehran. There- fore we inevitably executed a convenience non-random sampling method which might cause selection and vol- unteer bias. The lost data in the questionnaires brought about another limitation for this study. Since the miss- ing data could be most likely classified as “missing at random”, the analyses were not majorly affected and the estimated parameters were not biased by the ab- sence of data. Therefore the simplest approach of list- wise deletions was used for this matter. CONCLUSIONS Our study demonstrated that urologists continue to fa- vor PSA screening despite the current controversy on its usefulness. Most of the urologists practicing in Iran do not choose DRE as part of their screening program. Large high quality studies are needed to look into urol- ogist’s attitudes towards PCa screening, and to investi- gate their preferences in order to understand the ration- ale behind their decisions. CONFLICTS OF INTEREST None declared. REFERENCES 1. Hsing AW, Tsao L, Devesa SS. International trends and patterns of prostate cancer incidence and mortality. Int J Cancer. 2000;85:60-7. 2. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71- 96. 3. Ross LE, Coates RJ, Breen N, Uhler RJ, Potosky AL, Blackman D. Prostate-specific antigen test use reported in the 2000 National Health Interview Survey. Prev Med. 2004;38:732-44. 4. 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