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Shared Decision Making for Prostate Cancer

Insights From: E. David Crawford, MD, University of Colorado in Denver; Matthew T. Rosenberg, MD, Allegiance Health Systems; Daniel Petrylak, MD, Yale School of Medicine
Published: Wednesday, Dec 14, 2016



Transcript:

E. David Crawford, MD:
One of the issues of this informed decision, and that was brought forward, is that everyone should have [a shared decision based on the PSA value]. Maybe you could discuss that for a second. And the other thing you said is that we have a simple PSA level of 1.5 ng/dL, rather than a percent-free PSA, complex PSA, PSA cutoff of 2.54, and all these other things that confuse you guys. Tell us about this informed decision and then just finish up. You’re unique the way you feel. What about the other family practice doctors you talk to?

Matthew T. Rosenberg, MD: Those are a lot of questions, so let me try to get to all of them the best I can. First of all, if you look at the guidelines, they all talk about shared decision making, just as you were saying “informed decision.” It’s the same thing. There are three tenets of shared decision making, and in those tenets you basically need to inform the patient, you need to elicit their opinion, and you need to guide them on the right thing to do. Dan, you said this to me about 2 years ago, and I’ve quoted you a thousand times now. You said, and you’re about as well educated in this as anybody, it would take 23 minutes to do shared decision making in the world of prostate cancer for a patient or prostate screening. So, let’s look at how that pertains to the people using the PSA. The bulk of PSAs, as we already said, were primary care, so do I have 23 minutes per patient per exam when I’m getting a PSA to have that kind of decision or that kind of discussion with the patient when I’m not even that well trained in urologic disease? In primary care, I’m the master of nothing, but the knower of everything. I have to deal with all this stuff, so I need a simple way to do it. The bottom line is, when the US Preventive Services Task Force said shared decision making, when the AUA said it, when every group said this, they were wrong. They didn’t understand our audience.

Now, how do we move forward from that? What primary care physicians need is a simple way to do this without missing anything. If we go back to identifying prostate cancer patients when they’re already metastatic, then we’ve done the wrong thing. That’s the bottom line. We need to catch them early on with this. How do we do that? We educate them, with the 1.5 number. And you and I have worked on this now for a while, that’s going to be our answer. And 1.5, first of all, is not that common. The study I did out of some data from the bioreference lab, we looked at 217,000 PSAs that were drawn in 1 year for patients between the ages of 40 and 75. The reality of it is, in a screening population, 73% of the PSAs were less than 1.5.

E. David Crawford, MD: So, we only have to really work with about 30% of men, and that’s where the informed decision comes in.

Matthew T. Rosenberg, MD: That’s where it comes in. So, now we bring our population to something we could handle, and there’s something that you taught me years ago, which is we should be using the PSA as a vital sign. It’s a number; we don’t treat a number. We use a number and evaluate it, and take care of it appropriately. If I get that PSA and it’s elevated—1.5 or more—and I use it as a vital sign, as you’ve suggested, then I go into the shared decision making with the patient. And now I can really do something and say, “Look, this is where your risk goes up. Maybe we need some more information. I could refer you off or get a biomarker,” and we can catch that patient who’s at that risk for that aggressive, life-threatening disease.

Transcript Edited for Clarity
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Transcript:

E. David Crawford, MD:
One of the issues of this informed decision, and that was brought forward, is that everyone should have [a shared decision based on the PSA value]. Maybe you could discuss that for a second. And the other thing you said is that we have a simple PSA level of 1.5 ng/dL, rather than a percent-free PSA, complex PSA, PSA cutoff of 2.54, and all these other things that confuse you guys. Tell us about this informed decision and then just finish up. You’re unique the way you feel. What about the other family practice doctors you talk to?

Matthew T. Rosenberg, MD: Those are a lot of questions, so let me try to get to all of them the best I can. First of all, if you look at the guidelines, they all talk about shared decision making, just as you were saying “informed decision.” It’s the same thing. There are three tenets of shared decision making, and in those tenets you basically need to inform the patient, you need to elicit their opinion, and you need to guide them on the right thing to do. Dan, you said this to me about 2 years ago, and I’ve quoted you a thousand times now. You said, and you’re about as well educated in this as anybody, it would take 23 minutes to do shared decision making in the world of prostate cancer for a patient or prostate screening. So, let’s look at how that pertains to the people using the PSA. The bulk of PSAs, as we already said, were primary care, so do I have 23 minutes per patient per exam when I’m getting a PSA to have that kind of decision or that kind of discussion with the patient when I’m not even that well trained in urologic disease? In primary care, I’m the master of nothing, but the knower of everything. I have to deal with all this stuff, so I need a simple way to do it. The bottom line is, when the US Preventive Services Task Force said shared decision making, when the AUA said it, when every group said this, they were wrong. They didn’t understand our audience.

Now, how do we move forward from that? What primary care physicians need is a simple way to do this without missing anything. If we go back to identifying prostate cancer patients when they’re already metastatic, then we’ve done the wrong thing. That’s the bottom line. We need to catch them early on with this. How do we do that? We educate them, with the 1.5 number. And you and I have worked on this now for a while, that’s going to be our answer. And 1.5, first of all, is not that common. The study I did out of some data from the bioreference lab, we looked at 217,000 PSAs that were drawn in 1 year for patients between the ages of 40 and 75. The reality of it is, in a screening population, 73% of the PSAs were less than 1.5.

E. David Crawford, MD: So, we only have to really work with about 30% of men, and that’s where the informed decision comes in.

Matthew T. Rosenberg, MD: That’s where it comes in. So, now we bring our population to something we could handle, and there’s something that you taught me years ago, which is we should be using the PSA as a vital sign. It’s a number; we don’t treat a number. We use a number and evaluate it, and take care of it appropriately. If I get that PSA and it’s elevated—1.5 or more—and I use it as a vital sign, as you’ve suggested, then I go into the shared decision making with the patient. And now I can really do something and say, “Look, this is where your risk goes up. Maybe we need some more information. I could refer you off or get a biomarker,” and we can catch that patient who’s at that risk for that aggressive, life-threatening disease.

Transcript Edited for Clarity
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