Balancing Shared Decision-Making with Population-Based Recommendations: A Policy Perspective of PSA Testing and Mammography Screening

Abstract

AbstractPopulation-based screening programs invite otherwise healthy people who are not experiencing any symptoms to be screened for cancer. In the case of breast cancer, mammography screening programs are not intended for higher risk groups, such as women with family history of breast cancer or carriers of specific gene mutations, as these women would receive diagnostic mammograms. In the case of prostate cancer, there are no population-based screening programs available, but considerable access and use of opportunistic testing. Opportunistic testing refers to physicians routinely ordering a PSA test or men requesting it at time of annual appointments. Conversations between patients and their physicians about the benefits and harms of screening/testing are strongly encouraged to support shared decision-making. There are several issues that make this risk scenario contentious: cancer carries a cultural dimension as a ‘dread disease’; population-based screening programs focus on recommendations based on aggregated evidence, which may not align with individual physician and patient values and preferences; mantras that ‘early detection is your best protection’ make public acceptance of shifting guidelines based on periodic reviews of scientific evidence challenging; and while shared decision-making between physicians and patients is strongly encouraged, meaningfully achieving this in practice is difficult. Cross-cutting these tensions is a fundamental question about what role the public ought to play in cancer screening policy.