Australian general practitioners' views and use of tests to detect early prostate cancer

To describe general practitioners' current beliefs, knowledge and self-reported practices in prostate cancer screening, we conducted a national survey of 1,271 general practitioners, obtaining 855 completed questionnaires (67% response rate). Available tests for prostate cancer screening, namely DRE and PSA alone and in combination, were indicated to be effective by 49%, 43% and 68% of respondents respectively, with older GPs significantly more likely to hold these views. The effect of guidelines was mixed. Less than 8% of respondents indicated they did not recommend screening. Although the majority of GPs were unlikely to adopt an opportunistic approach to prostate cancer screening, 63%, 57% and 46% indicated they would recommend DRE, PSA or both respectively during a dedicated health check up. Awareness of relevant guidelines was low, with nearly half of respondents unable to recall publications from the RACGP or ACS. Counter-intuitively, awareness of ACS guidelines for prostate cancer screening (which advise against screening) was significantly associated with the converse behaviour. Findings from this first national study behove proactive and highly targeted dissemination in general practice of the AHTAC policy announced by the Commonwealth Health Minister in August 1996.     

Screening for prostate cancer in U.S. men ACPM position statement on preventive practice

INTRODUCTION: Prostate cancer is the leading cancer in U.S. men, and the third leading cause of cancer deaths. Principal screening tests for detection of asymptomatic prostate cancer include digital rectal examination (DRE) and measurement of the serum tumor marker, prostate-specific antigen (PSA). There are risks and benefits associated with prostate cancer screening. Randomized controlled trials of screening by DRE and PSA are limited to two previously published studies. Two other large-scale randomized controlled trials are currently in progress. METHODS: This study reviewed the efficacy of DRE and PSA for prostate cancer screening found in the medical literature prior to July 2007. RESULTS: Applications of PSA screening tests used in clinical practice include (1) a PSA cutoff of 4 ng/ml, (2) age-specific PSA, (3) PSA velocity, (4) PSA density, and (5) percent free PSA. Prostate cancer screening can detect early disease and offers the potential to decrease morbidity and mortality. Prostate cancer screening benefits, however, remain unproven, pending results of ongoing trials. There is currently no convincing evidence that early screening, detection, and treatment improves mortality. Limitations of prostate cancer screening include potential adverse health effects associated with false-positive and negative results, and treatment side effects. CONCLUSIONS: The American College of Preventive Medicine concludes that there is insufficient evidence to recommend routine population screening with DRE or PSA. Clinicians caring for men, especially African-American men and those with positive family histories, should provide information about potential benefits and risks of prostate cancer screening, and the limitations of current evidence for screening, in order to maximize informed decision making.     

Meta-analysis of prostate-specific antigen and digital rectal examination as screening tests for prostate carcinoma

BACKGROUND: Physicians commonly screen for prostate cancer by using prostate-specific antigen (PSA) and digital rectal examination (DRE). The usefulness of these screening mechanisms is not well established, however. A meta-analysis of PSA and DRE to detect prostate carcinoma was conducted with a focus on sensitivity, specificity, and positive predictive value. METHODS: A literature search of OVID database (1966 to November 1999) using the medical subject headings "prostate-specific antigen" and "mass screening," as well as "prostate carcinoma," was performed. Thirteen articles were selected for the meta-analysis in this study. Most studies included asymptomatic men older than 50 years from various countries. Pooled results were calculated from the individual reports for sensitivity, specificity, and positive predictive value for PSA and DRE based on biopsy result as the reference standard. RESULTS: The overall detection rate of prostate carcinoma was 1.8% based on a positive biopsy. Of the prostate carcinoma detected, 83.4% was localized. The pooled sensitivity, specificity, and positive predictive value for PSA were 72.1%, 93.2% and 25.1%, respectively; and for DRE were 53.2%, 83.6% and 17.8%, respectively. CONCLUSIONS: There were two major outcomes of this meta-analysis. One was the potential for detecting early-stage prostate cancer with these screening tests, because 83.4% of total cancers detected were localized. The second important outcome was that the overall sensitivity, specificity, and positive predictive value for PSA were higher than those for DRE when used as a screening tool to detect prostate cancer. When a patient has abnormal findings using PSA and DRE, the chance of cancer is 1 in 4 or 5. Conversely, when findings from PSA and DRE are normal, the chance of missing a cancer is about 10%.     

The validity of male patients' self-reports regarding prostate cancer screening

BACKGROUND: Despite the high rate of prostate cancer screening, the accuracy of male patients' self-reports of screening has not been investigated. This study assessed the concordance between patients' self-reports of prostate screening and the medical record. METHODS: Focus groups were conducted to obtain male patients' perceptions of prostate cancer screening and salient terminology. A sample of males (n = 276), 40 years of age or older, completed a 15-item questionnaire. Patients' self-reports of PSA and DRE screening were then compared with medical records. RESULTS: Results showed that patients' self-reports of DRE and PSA were discordant with the medical record 32 and 29% of the time, respectively. Sensitivity of patients' self-reports for DRE and PSA was 82 and 74%, respectively. Specificity of patients' self-reports for DRE and PSA was 56 and 65%, respectively. One in five patients reported that they were not sure how a doctor checks a man's prostate gland. Only 39% of patients knew that the prostate gland can be checked by a blood test. CONCLUSIONS: There were significant differences between patients' self-reports and the medical record. The results should be of concern to primary care practitioners and to those who evaluate the efficacy of prostate cancer screening programs.     

Low-literacy interventions to promote discussion of prostate cancer: a randomized controlled trial

BACKGROUND: Professional organizations recommend that physicians discuss prostate cancer with patients to make individual screening decisions. However, few studies have tested strategies to encourage such discussions, particularly among high-risk populations. We examined the effects of two low-literacy interventions on the frequency of prostate cancer discussion and screening. DESIGN: Randomized, blinded, controlled trial with concealed allocation. SETTING/PARTICIPANTS: Inner-city primary care clinic, serving a predominately African-American population. Participants were men aged 45-70 with no history of prostate cancer, presenting for a regular appointment. INTERVENTIONS: While waiting to see their physician, patients received a patient education handout on prostate cancer screening (PtEd), a handout simply encouraging patients to talk to their doctor about prostate cancer (Cue), or a control handout. The interventions did not advocate for or against screening. MEASURES: Patient-reported discussion of prostate cancer with the physician and chart reviews determine prostate-specific antigen (PSA) test orders and performance of digital rectal examination (DRE). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were computed. Data were collected in 2003, and analyses were completed in 2006. RESULTS: Most of the 250 subjects (90.4%) were African American and 78.8% read below the ninth grade level. Overall, 48.4% reported discussing prostate cancer during the appointment. Compared to the control group (37.3%), discussions were significantly more common in the Cue group (58.0%, aOR=2.39 [1.26-4.52]), as well as in the PtEd group (50.0%, aOR=1.92 [1.01-3.65]). When prostate cancer was discussed, patients in the intervention groups more commonly initiated the conversation (47.6% PtEd and 40.0% Cue, vs 9.7% control, p<0.01 for each comparison to control). Compared to the control group (2.4%), PSA test orders increased in the PtEd group (14.1%, aOR=7.62 [1.62-35.83]) and in the Cue group (12.3%, aOR=5.86 [1.24-27.81]). Documentation of DRE did not change significantly (4.7% PtEd, 6.2% Cue, and 6.0% control). CONCLUSIONS: Two simple low-literacy interventions significantly increased discussion of prostate cancer and PSA test orders but not performance of DRE. Both interventions were effective in empowering low-literacy patients to initiate conversations about prostate cancer with their physician.     

Cost-effectiveness analysis of prostate cancer screening

To determine the optimal strategy for prostate cancer screening, the cost-effectiveness of screening was analyzed using a medical decision model. One hundred thousand asymptomatic males between the ages of 40 and 69 were modeled with and without screening. The subjects were divided into three 10-year age groups. We used a 5-year survival rate as an effectiveness point and assumed after 5 year survival free from prostate cancer. We considered three potential programs: 1) screening with digital rectal examination (DRE), 2) screening with prostate specific antigen (PSA), and 3) screening with a combination of DRE and PSA. The study was analyzed from the payer’s perspective, and only direct medical costs were included. For each of the three age groups, PSA screening was more cost-effective than either DRE screening or a combination of DRE and PSA screening. The cost-effectiveness ratio for the combination of DRE and PSA screening was 1.1–2.3 times more expensive dian that of PSA screening. If the compliance rate for work-up exams is 80%, the cost-effectiveness of prostate cancer screening is approximate to that of gastric cancer screening. In conclusion, PSA screening is the most cost-effective strategy for prostate cancer screening when compared with both DRE and the combination of DRE and PSA screening. But prostate cancer screening should be carefully conducted, taking the cost-effectiveness of the different strategies and target groups into consideration.     

Effectiveness of screening for prostate cancer: A nested case-control study

Although screening for prostate cancer with prostate-specific antigen (PSA) or digital rectal exam (DRE) is commonly done, evidence is currently lacking to show a benefit of such testing on survival. The current study used a nested case-control design to assess the impact of screening with PSA (with or without DRE) on mortality.Among 71,661 patients receiving ambulatory care during 1989–1990 at any of ten VA Medical Centers in New England, case subjects were men diagnosed with prostate cancer from 1991–1995 who died during 4–9 years of follow-up. Control subjects (1:1 sampling ratio) were men who are alive at the time of death of the corresponding case, matched for year of birth and VA facility. The exposure variables were screening with PSA alone, or PSA and DRE, done for screening purposes; potential screening tests must have occurred prior to the diagnosis of prostate cancer for the cases or the corresponding date for controls. The assessment of screening was also done blind to case-control status, and tests were classified by an algorithm that took into account the clinical context of the exams.A total of 501 matched case and control subjects (1002 total patients) were included in final analyses. The frequency of screening with PSA was similar among cases (14.0%) and controls (13.0%); with an unadjusted odds ratio of 1.10 (95% C.I. 0.75 to 1.62). After adjusting for race and comorbidity, the odds ratio remained quantitatively and statistically non-significant at 1.08 (95% C.I. 0.71 to 1.64). Screening was also not associated with improved survival in analyses involving screening with PSA or DRE, among men less than 70 years of age, and using data from patients during last three years of intake when PSA testing was more commonly done.The results do not support the effectiveness of PSA or DRE in screening for prostate cancer.     

#7-S the efficacy of the digital rectal examination,total prostate specific antigen,and prostate specific antigen ratio algorithm in diagnosing prostate cancer

PURPOSE: The primary objective of this study was to determine the efficacy of the algorithm Digital Rectal Examination (DRE), Prostate Specific Antigen (PSA), and free/total Prostate Specific Antigen ratio (PSAr) in diagnosing prostate cancer. A criterion of 1 test, 2 tests and all 3 tests being positive was utilized for the DRE/PSA/PSAr algorithm.METHODS: A sample of 446 males suspected for prostate cancer was referred for transrectal ultrasound and biopsy. All patients consented to participate by allowing venipuncture and DRE prior to sextant biopsy examination. Analysis of PSA and PSAr were performed using Abbott Diagnostics kits. Statistical analysis in determining diagnostic utility for DRE/PSA/PSAr included ROC curve analysis, calculated sensitivity (Sens), specificity (Spec), and likelihood ratio (LR) with corresponding 95% confidence intervals (CI) as well as Kappa statistics.RESULTS: Positivity criteria for PSA and PSAr were identified at >4 and <0.15, respectively. The algorithm of DRE/PSA/PSAr ([Sens = 99%; CI, 1%] [Spec = 3%; CI, 2%], {LR = 1.02; CI, 0.05} demonstrated no significant Kappa agreement (p > 0.05) with the confirmed diagnosis for prostate cancer. The algorithm of DRE/PSA/PSAr with a criterion of one test being positive ([Sens = 99%; CI, 1%] [Spec = 3%; CI, 2%], [LR = 1.02; CI, 0.05] demonstrated no significant Kappa agreement (p > 0.05) with the confirmed diagnosis for prostate cancer. Furthermore, DRE/PSA/PSAr with a criterion of two tests being positive ([Sens = 83%; CI, 5%], [Spec = 61%; CI, 6%], [LR = 2.13; CI, 0.07]) indicated significant Kappa agreement (p < 0.0001).CONCLUSIONS: This study concluded that the algorithm of DRE/PSA/PSAr, with a criterion of one test being positive, failed to enhance specificity compared to the traditional algorithm of DRE/PSA. Furthermore, the algorithm DRE/PSA/PSAr with a criterion of two tests being positive did enhance specificity but sacrificed sensitivity.     

Demographic and past screening behaviors of men attending a free community screening program for prostate cancer

This study characterizes demographic and past prostate screening behaviors of men who participated in a free screening for prostate cancer. Demographics, past prostate screening behavior, perceived risk, and cancer worry were assessed in 1,680 men. Mean age was 58.2 years, 56% were White, and 76% had health insurance. Men with insurance were more likely to have had a previous prostate-specific antigen (PSA) test and digital rectal exam (DRE). White men were more likely to have had a previous PSA and DRE and to have discussed PSA testing with a physician than African American men. African American men reported greater perceived risk and more worry than White men. Screening differences between African American and White men were explained by insurance status. These results may help guide the development of and promotion for future screening programs. Future efforts should be directed at increasing awareness about screening procedures for prostate cancer.     

Who uses decision aids? Subgroup analyses from a randomized controlled effectiveness trial of two prostate cancer screening decision support interventions

OBJECTIVE: To examine who reported using unsolicited prostate cancer screening decision aids distributed as part of a randomized controlled trial, whether reported use varied by type of aid (video or pamphlet), and what affect reported use had on study outcomes. METHODS: A total of 1,152 men aged 50 and older from four medical facilities in the United States were randomly assigned to pamphlet, video or usual care (control). Materials were mailed 2 weeks prior to clinic appointments in general internal medicine. Outcomes were assessed by phone survey 1 week after appointments. Analyses examined the reported use of materials by study group, the association between patient characteristics and reported use, and the impact of reported use (adjusting for patient characteristics) on a 10-item knowledge index. RESULTS: Fifty-six percent of those randomized to receive the video and 50% of those randomized to receive the pamphlet reported using the materials. Reported use of the video was higher for patients who had greater than a high school education (OR 1.73), were married (OR 2.20), and reported no prior abnormal prostate cancer screening test results (OR 3.39). Reported use of the pamphlet did not vary by patient characteristics. In intent-to-treat analyses (ignoring reported use), individuals randomized to the video and pamphlet groups had significantly higher knowledge scores relative to the control group (7.44, 7.26 and 6.90 respectively). Adjusting for reported use modestly increased the estimated differences across treatment groups but did not substantially change conclusions about the relative effects of these aids on knowledge. CONCLUSIONS: Only half of men receiving unsolicited prostate cancer screening decision aids before a visit reported using the aids, and who reported using them varied by type of aid. Efforts to broadly implement decision aids may need to offer a variety of approaches, and incorporate creative strategies to enhance reaching all population subgroups.     

Patient education for informed decision making about prostate cancer screening: a randomized controlled trial with 1-year follow-up

PURPOSE: The efficacy of prostate cancer screening is uncertain, and professional organizations recommend educating patients about potential harms and benefits. We evaluated the effect of a videotape decision aid on promoting informed decision making about prostate cancer screening among primary care patients. METHODS: A group of 160 men, 45 to 70 years of age, with no history of prostate cancer, were randomized to view or not to view a 20-minute educational videotape before a routine office visit at a university-based family medicine clinic. The subjects were contacted again 1 year after their visit to assess their receipt of prostate cancer screening (digital rectal examination [DRE] or prostate-specific antigen [PSA] testing), their satisfaction with their screening decision, and knowledge retention since the baseline assessment. RESULTS: Follow-up assessments were completed for 87.5% of the intervention subjects and 83.8% of the control subjects. The rate of DRE did not differ between the 2 groups. Prostate-specific antigen testing was reported by 24 of 70 (34.3%) intervention subjects and 37 of 67 (55.2%) control subjects (P = .01). African American men were more likely to have had PSA testing (9 of 16, 56.3%) than were white men (13 of 46, 28.3%) (P = .044). Satisfaction with the screening decision did not differ between the study groups. Intervention subjects were more knowledgeable of prostate cancer screening than were control subjects, although these differences declined within 1 year (P < .001). CONCLUSIONS: Decision aids for prostate cancer screening can have a long-term effect on screening behavior and appear to promote informed decision making.     

Psychological benefits of prostate cancer screening: the role of reassurance

Objectives The role of reassurance in decision‐making about screening for health problems is largely unknown. We examined the reassurance value of prostate cancer screening in primary care patients. Setting and participants One hundred and sixty eight men, aged 45–70 years, who had no history of prostate cancer, from three family medicine practices in southeast Texas. Methods A hypothetical scenario was developed where men were asked to assume they did not have prostate cancer, and then to rank three predefined screening states with regard to reassurance value: (A) unknown (no screening), (B) normal by screening [a prostate‐specific antigen (PSA) test and a digital rectal examination (DRE)] and (C) normal by biopsy (abnormal PSA test and DRE results but a negative ultrasound‐guided prostate biopsy). Results Most of the men (96.8%) associated some reassurance value with screening, considering health state A to be the worst possible health state. Results from a multivariate analysis showed that preference for screening state C was associated with a family history of prostate cancer and perceived greater risk for prostate cancer compared with other men. Conclusion These findings suggest that prostate cancer screening may have some reassurance value for men, and that increased risk status may explain why some men prefer the added reassurance afforded by screening.     

Prostate-specific antigen test use reported in the 2000 National Health Interview Survey

BACKGROUND: In 2000, the National Health Interview Survey (NHIS) collected information about prostate-specific antigen (PSA) test use in a representative sample of U.S. men. METHODS: This study examined PSA test use in subgroups defined by personal and social characteristics. RESULTS: Among men aged 50 and older with no history of prostate cancer, 56.8% reported ever having had a PSA test, 34.1% reported having had a screening PSA test during the previous year, and 30.0% reported having had three or more tests during the previous 5 years. Screening was greater among men aged 60-79 years, those with greater access to care, and those practicing other preventive behaviors. Among men in their 40s, use tended to be higher among African-American men. CONCLUSIONS: The prevalence and patterns of PSA screening suggest that PSA is used like other cancer screening tests among about a third of U.S. men. Because of the lack of scientific consensus on whether prostate cancer screening is beneficial, more information is needed on how knowledgeable both patients and practitioners are about the potential benefits and harms of screening and how prostate cancer screening decisions are made.     

Prostate Cancer Screening—A Physician Survey in Missouri

This study investigated prostate cancer screening practices using prostate specific antigen testing (PSA), digital rectal examination (DRE), and transrectal ultrasonography (TRUS) by primary care physicians in Missouri. In 1993, a mail survey was sent to a stratified random sample of 750 physicians whose primary specialty was general practice, family practice, or internal medicine. Three separate mailings resulted in an overall adjusted response rate of 60 percent. Ninety-five percent of physicians were more inclined to use PSA compared with three years previously, with only 45 percent of physicians more inclined to use DRE. An increase in the use of PSA following a negative DRE was reported by 85 percent and a greater inclination to use TRUS following a positive PSA was reported by 90 percent Eighty-six percent agreed with the American Cancer Society (ACS) guidelines on prostate cancer screening. Using logistic regression adjusted across levels of demographic and practice factors, prevalence odds ratios were derived with results indicating that agreement with ACS guidelines and being in private practice are strong predictors of a physician's inclination to routinely screen asymptomatic patients for prostate cancer. Our findings have provided baseline information on prostate cancer screening in Missouri and suggest that primary care physicians view PSA testing as a useful procedure and appear to be using it in a manner similar to the general pattern seen across the country.     

Case-control prostate cancer screening studies should not exclude subjects with lower urinary tract symptoms

OBJECTIVE: Prostate-specific antigen (PSA)/digital rectal exam (DRE) screening for prostate cancer has become standard medical practice; however, its effectiveness in terms of reducing prostate cancer mortality remains undetermined. Case-control screening studies may help determine screening efficacy, though the proper disposition of symptomatic subjects is unclear. This paper presents a prostate cancer-specific methodological modification for analyzing symptomatic case-control screening subjects. METHODS: Prostate cancer detection studies and case-control studies of PSA/DRE screening were reviewed, and the results for symptomatic and asymptomatic subjects were compared. RESULTS: Most PSA/DRE detection studies have found that the prostate cancer detection rate among symptomatic patients is the same as or lower than that among asymptomatic patients. Lower urinary tract symptoms (LUTS), often referred to as early prostate cancer symptoms, occur more often in benign prostatic hyperplasia (BPH), a more commonly diagnosed, nonmalignant disease. Screened symptomatic subjects are usually removed from the "screened" category in case-control studies even though BPH-related symptoms do not confer increased prostate cancer risk and odds ratios do not change with inclusion of symptomatic subjects in the analysis. CONCLUSION: Screened subjects with LUTS should remain in the "screened" category in case-control prostate cancer screening studies since these symptoms may not be associated with increased risk of prostate cancer or validity of the odds ratio.     

Cultural Sensitivity and Informed Decision Making About Prostate Cancer Screening

Because informed consent for prostate cancer screening with prostate specific antigen (PSA) is recommended, we determined how African Americans, Hispanics, and Caucasians want information about screening with PSA and the digital rectal exam (DRE) presented in culturally sensitive brochures specific for each group. We analyzed focus group discussions using content analysis and compared themes across groups in a university outpatient internal medicine practice setting. The participants were twenty couples with men age 50 and older who participated in four focus groups. Main outcome measures were participants' views on the content and graphic design of culturally sensitive brochures promoting informed decision making about prostate cancer screening. There were content and graphic design differences in the way ethnic groups wanted information presented about the prostate, prostate cancer, risk, and screening. Caucasians likened the size of the prostate to a walnut; Hispanics, to a small lime. Hispanics emphasized how advanced prostate cancer can be symptomatic; Caucasians, how early prostate cancer can be asymptomatic. African Americans wanted risk information specific for them and the advantages and disadvantages of a PSA and DRE; Hispanics, did not. Caucasians and African Americans sought a more active role for men in informed decision making than Hispanics. Differences in the way African Americans, Hispanics, and Caucasians want information presented about prostate cancer screening suggest there may be cultural differences in the reasonable person standard of informed consent, in attitudes toward the physician–patient relationship, screening, and informed decision making. Physicians promoting informed decision making about controversial screening tests should take cultural sensitivity into account when designing educational interventions and using them.     

An analysis of digital rectal examination and serum-prostate-specific antigen in the early detection of prostate cancer in general practice

BACKGROUND: Prostate cancer is now the commonest cancer in men and the second commonest cause of death from cancer. However, general-practice-based research on prostate cancer remains scanty. OBJECTIVES: We aimed to examine the acceptability of digital rectal examination (DRE) and serum-prostate-specific antigen (PSA) in the early detection of prostate cancer in a general practice setting. Another aim was to ascertain the incidence of prostate cancer among 50-79-year-old men in the solo practice. METHODS: We conducted an opportunistic, prospective, population-based study involving men with no prior, proven history of prostate cancer. RESULTS: A total of 211 (87.6%) out of 241 targeted patients agreed to take part in the study. Abnormal DREs were found in 9%, while 9.5% of PSA tests were found to be abnormal. One or both tests were abnormal in 29 patients-13.7% of the study population. Eleven biopsies were performed during the study, with cancer detected in three (27.3%)-1.4% of the total population. Eighteen patients were not biopsied either on clinical grounds or by personal choice. CONCLUSIONS: The incidence of abnormal DRE and PSA tests was lower than that detected in previous hospital or specialist-based studies. Both tests were found to be highly acceptable to the population studied. Not all patients with abnormal early detection tests need necessarily proceed to further invasive investigations.     

A randomized controlled trial of shared decision making for prostate cancer screening.

OBJECTIVE: To evaluate a patient-educational approach to shared decision making for prostate cancer screening. DESIGN: Randomized controlled trial with preoffice visit assessment and 2-week follow-up. SETTING: University-based family practice center. PATIENTS: Men aged 45 through 70 years with no history of prostate cancer or treatment for prostate disease (N = 160). Two patients were unavailable for follow-up. INTERVENTION: Twenty-minute educational videotape on advantages and disadvantages of prostate-specific antigen (PSA) screening for prostate cancer. MAIN OUTCOME MEASURES: A measure of patients' core knowledge of prostate cancer developed for this study, reported preferences for PSA testing, and ratings of the videotape. RESULTS: Patients' core knowledge at baseline was poor. At 2-week follow-up, subjects undergoing videotape intervention showed a 78% improvement in the number of knowledge questions answered correctly (P = .001), and knowledge increased about mortality due to early-stage prostate cancer, PSA screening performance, treatment-related complications, and disadvantages of screening. No overall change was observed for control subjects. At follow-up, 48 (62%) of 78 intervention patients planned to have the PSA test compared with 64 (80%) of 80 control patients (18.5% absolute reduction; 95% confidence interval, 4.6%-32.4%; P = .009). Intervention subjects rated favorably the amount of information provided and the clarity, balance, and length of the videotape and would recommend the videotape to others. CONCLUSIONS: Patient education regarding the potential benefits and harms of early detection of prostate cancer can lead to more informed decision making. Incorporating the PSA videotape into the periodic health examination for asymptomatic men aged 50 years and older is recommended.     

Screening by prostate-specific antigen and digital rectal examination in relation to prostate cancer mortality: a case-control study

BACKGROUND: The potential role of prostate cancer screening in reducing mortality is uncertain. To examine whether screening with the prostate-specific antigen (PSA) test or digital rectal examination is associated with reduced prostate cancer mortality, we conducted a population-based case-control study in 4 health maintenance organizations. METHODS: Cases were 769 health plan members who died because of prostate adenocarcinoma during the years 1997-2001. We randomly selected 929 controls from the health plan membership and matched them to cases on health plan, age, race, and membership history. Medical records were used to document all screening tests in the 10 years before and including the date on which prostate cancer was first suspected. RESULTS: Among white participants, 62% of cases and 69% of controls had a least 1 screening PSA test or digital rectal examination (odds ratio = 0.73; 95% confidence interval = 0.55-0.97). The corresponding proportions for blacks were 59% and 61% (1.0; 0.59-1.4). Most screening tests were digital rectal examinations; therefore, in the subgroup with no history of PSA screening, the association between digital rectal screening and prostate cancer mortality was similar to the overall association (0.65 [0.48-0.88] among whites; 0.86 [0.53-1.4] among blacks). Very few men received screening PSA without screening digital rectal examination (6% of cases and 7% of controls among whites). CONCLUSIONS: Digital rectal screening was associated with a reduced risk of death due to prostate cancer in our population. Because of several data limitations, this study could not accurately estimate the effect of PSA screening separate from digital rectal examination.     

A nested case-control study of the effectiveness of screening for prostate cancer: research design

Although prostate-specific antigen (PSA) and digital rectal examination (DRE) are commonly used to screen for prostate cancer, available data do not confirm that either test improves survival. This report describes the methodological aspects of a nested case-control study addressing the question of whether PSA screening, with or without DRE, is effective in increasing survival. Potential sources of bias are discussed, as well as corresponding strategies used to avoid them. Results are expected in the year 2002.