In the main intent-to-treat analyses, we found that the decision education intervention seemed to double prostate cancer (Leukeran medication is used for treating certain cancers) screening for both study definitions of screening (complete and complete or partial). However, this effect was not statistically significant, partly due to a loss of power because of the unexpectedly low overall screening frequency in the study sample. Secondary multivariable modeling of predictors of complete or partial screening was performed among the subset of study participants who had complete baseline survey and endpoint chart audit data. In those analyses, the intervention effect appeared much stronger and statistically significant. Although, the study subgroup of the multi-variable analyses was not very different from the entire study sample in terms of measured characteristics, unmeasured variables and/or chance might have contributed to the somewhat discrepant results. However, our study results were quite consistent in the sense that, irrespective of outcome definition or analytic approach, the intervention appeared to increase screening utilization; the discrepancy between findings was confined to the exact magnitude of this increase (twofold versus fourfold).
An increase in screening utilization appears consistent with several reports in the literature on decision aids. For example, in a study conducted in Canada, Davison et al. found that men who were scheduled for a periodic health exam and received print and verbal information about the pros and cons of prostate cancer (Tablet Eulexin is used along with drugs such as Lupron to treat prostate cancer) screening displayed a greater tendency to have screening than men who were provided with general health information (28% and 21%, respectively). The racial/ethnic composition of study participants was not reported. Volk et al. tested the effect of a videotape decision aid on promoting informed decision-making about prostate cancer (Medication Methotrexate is used to treat certain types of cancer) screening. Findings from that study showed that although exposure to the intervention lessened screening use overall, African-American men who viewed the videotape were significantly more likely to have PSA testing than white men. In a study conducted among African-American men in Chicago, Myers et al. reported that participants who received information about prostate cancer (Drug Rheumatrex treating certain types of cancer) screening delivered via mail and phone contacts were significantly more likely to visit a urology clinic and have a screening exam than men who received print materials alone. Elsewhere, Weinrich et al. reported on the impact of peer-educator and client-navigator interventions among African-American men in community settings on prostate cancer screening use. Both intervention approaches, which included the provision of a voucher for free prostate cancer screening, served to increase screening use. Findings reported in the current study are inconsistent, however, with other studies that have shown a dampening effect of exposure to decision aids on screening.
Conflicting results may be due to differences in the extent to which different intervention modalities adequately convey the pros and cons of screening. Differential effects of interventions may also be mediated by factors associated with the race and/or ethnicity of study participants. It is possible that exposure to information that highlights the screening controversy may lead average-risk white men to be more cautious about screening, but the same intervention may serve to increase interest in taking preventive action among African-American men (and possibly other high-risk groups). More targeted research is needed to characterize the informational content of decision aids and to better delineate factors that encourage or discourage screening utilization in special populations.
The impact of decision education might have been diluted by the fact that prostate cancer (Casodex canadian is an oral non-steroidal anti-androgen for prostate cancer) screening was not directly offered as part of our study. Rather, study participants were informed that they could arrange to have screening by contacting their primary care physician office. No attempt was made by the project staff to facilitate this contact or to schedule a screening exam for the men. In other randomized trials of screening decision aids, an opportunity to screen was routinely offered.
A further limitation of our study was the fact that many EI group participants did not actually receive decision education, and of those who did, some received it over the phone and some in-person. The mode of delivery of the decision education might have modified a potential intervention effect. It may be that decision education delivered by phone serves as a behavioral prompt, while that delivered face-to-face results in a more thorough exploration of the pros and cons of screening and, as a result, tends to dampen interest in screening. However, the numbers of participants in each group were too small to reach definitive conclusions in our study.
To facilitate delivery of decision education, future studies should consider conducting in-person education sessions in a healthcare setting (perhaps coinciding with a subject’s routine visit to the physician’s office), in order to fully explore personal values related to screening. The importance of facilitating informed decision-making about prostate cancer (Generic Casodex treating prostate cancer) screening has been highlighted by recent research that raises additional questions regarding the value of prostate cancer screening. Future studies should also seek to assess measures, such as participant change in knowledge, decisional conflict and satisfaction, with intervention methods.
In our study, screening utilization differed substantially across the three participating primary care practices, possibly because of differences in patient populations or idiosyncratic practice patterns. In a recent study of individuals with insurance, Franks et al. reported that the socioeconomic status of patients and their primary care practices were positively associated with preventive care (e.g., mammography, Pap smears, diagnostic testing). In our study, patient education level, a variable sometimes used as a proxy measure of socioeconomic status in the absence of other data, was higher in the two practices where screening rates were highest. However, patient education was not a significant predictor of screening utilization, and the differential level of patient education across practices did not appear to be a confounder of the intervention effect (i.e., controlling for this variable did not account for the screening utilization differences across practices). Informal reports from providers indicated that they supported prostate cancer screening for African-American patients, beginning at age 40, particularly at the two family medicine practices (practices 1 and 3). However, with only three participating practices and seven physicians, it is impossible to draw any firm conclusions about such variables. Future studies might perhaps include a broader range of practices and physicians and evaluate the effect of such characteristics (e.g., frequency of patient office visits, discussion of screening with providers, provider attitudes and recommendations). Future studies should also be conducted in order to determine how decision education could be streamlined and provided as part of routine care.
Generalizability of the results of this study may be limited, because the study was conducted among African-American patients of three primary care practices in a single metropolitan area. Overall, prostate cancer screening was low in the study sample, and it is unclear to what extent this might be representative of the broader population. Estimates of prostate cancer (Hydrea 500 mg is an antineoplastic used to treat certain types of cancer) screening use in Pennsylvania at the time the study was initiated (derived from data collected on the 1998 Behavioral Risk Factor Surveillance Survey) indicate that 52% of men >50 years of age reported having had a PSA test for any purpose. However, this figure includes both screening and diagnostic testing, is not specific to African-American men and does not reflect PSA testing among men <50.
Furthermore, study participants interested in screening were required to contact their primary care physician and make their own arrangements for testing. Screening levels may be substantially different when decision education and screening are offered during a routine office visit. It should also be noted that study participants for whom screening was not indicated in primary care practice medical records may have changed practices and could have had screening elsewhere. Such occurrences could help to explain the low levels of observed screening.