Determining an appropriate cancer screening regimen is one of the most important and challenging preventive care tasks in primary care. Providers must evaluate the evidence on the effectiveness of multiple screening tests, decide which tests to offer, identify patients who are eligible for screening, reach agreement with eligible patients about which tests to perform, appropriately follow up on the results of screening, and identify when the tests will need to be performed again. Some forms of screening, such as mammography for breast cancer, have reached large segments of the eligible population. However, current health care delivery models continue to have significant difficulty ensuring that eligible patients are aware of the availability of effective screening interventions and are able to take advantage of them.
Two articles in this issue of JGIM illustrate how inadequate patient–provider communication limits the quality of cancer screening. Ling et al. performed a survey of patients' and providers' attitudes about different options for colorectal cancer (CRC) screening.1 They provided participants with structured educational information about 5 CRC screening options considered effective by a 1997 expert panel. Most patients preferred either fecal occult blood testing (FOBT) alone (43%) or colonoscopy (40%). Patients who attached the highest value to test accuracy most often chose colonoscopy, while patients who considered the frequency, complications, discomfort, or inconvenience of the test most important were more likely to choose FOBT. Interestingly, although patients and providers were similar in how they valued different test characteristics, physicians vastly overestimated the value patients placed on discomfort and underestimated the value they placed on accuracy. The effect of this misperception on the tests that providers recommend to patients is not clear, but raises concern that providers may be selecting tests that do not reflect patients' values. Further research is required to determine if this mismatch reduces test completion rates or patient satisfaction, and to determine if better information and communication about values and preferences will improve screening rates and satisfaction.
Voss and Schectman examine another important issue in cancer screening: the use of prostate-specific antigen (PSA) screening for prostate cancer.2 PSA screening presents a different communication dilemma: how should providers and patients discuss and decide about screening in the face of uncertainty about its effectiveness in reducing mortality? Voss and Schectman present data from a longitudinal survey of physician providers from 1993 and 1998. Physicians reported ordering PSA screening as part of regular health maintenance visits 73% of the time in 1993 and 81% in 1998. Physician support for PSA testing increased over the same time period, despite the fact that over 50% of providers were either uncertain or did not believe that aggressive therapy reduced mortality. Providers in busy practices were more likely to order testing, as were those furthest from training; academic physicians were less likely to order testing than community physicians. PSA use was associated with the perception that testing represented “standard of care” practice and concerns about malpractice liability if screening were not offered; it was inversely associated with the belief that the harms of screening may outweigh the benefits. Many providers who were classified as “high testers” (i.e., reported ordering PSA in over 80% of their patients) also agreed that the harms of treatment might outweigh the benefits. The authors hypothesize that under the condition of uncertainty about treatment efficacy, but increasing public interest and awareness of PSA, busy practitioners may choose to perform testing rather than engage in a shared discussion about the pros and cons of screening.
The studies by Ling et al. and Voss and Schectman both illustrate how lack of communication between providers and patients acts as a barrier to the provision of high-quality preventive care. Surveys of providers suggest that a lack of time is perceived as one of the main reasons for a failure to discuss screening.3 Recent research has suggested that decision aids, systematically developed tools that use videodiscs or computers to provide relevant information to patients about their options, can help patients who are facing screening decisions to make more informed decisions, and may also improve adherence and satisfaction.4,5 Because such tools are used before the patient sees the provider, they can help focus the discussion, reduce the perception of inadequate time, and allow better communication of patient values. —