DR. LIANG: Prostate cancer is a common disease among men in the United States. Although its high prevalence and potential mortality risk would seem to warrant routine screening programs for early detection and treatment, the utility of such programs is currently under debate, as is illustrated by this case study. This lack of consensus has led to the development of a variety of approaches to informing patients regarding their options. Cancer-screening recommendations of national medical organizations in the United States differ wide- ly. The American Cancer Society recommends that men 40 years and older be informed by their physi- cians about the risk for prostate cancer, 1 and that men 50 years and older be offered a digital rectal examina- tion (DRE) as well as the prostate-specific antigen (PSA) test at their annual physical examination. 2 The American Urological Association endorses the Amer- ican Cancer Society’s recommendations. 2 In contrast, most other medical organizations do not advocate routine screening for patients at risk for prostate cancer, citing the significant side effects of surgery for prostate cancer (eg, incontinence, impo- tence) and the lack of current rigorous evidence that early detection and treatment substantively affect the overall death rate. The US Preventive Services Task Force, the American College of Surgeons, the Amer- ican Society of Internal Medicine, the National Cancer Institute, the American Association of Family Practi- tioners, and the American College of Preventive Medi- cine all indicate that routine screening for prostate cancer is not recommended. 3,4 Various national organi- zations in other countries also recommend against rou- tine screening; literature from Sweden indicates that physicians there generally do not screen for prostate cancer and treatment is usually watchful waiting. 5 Although a strong and legitimate set of groups cur- rently recommend against routine prostate cancer test- ing, an increasing number of men in the United States are receiving such testing. 6 Because of this increased preference for testing, it is ever more important to provide accurate and adequate counseling as to the strengths and weaknesses of the PSA test and the DRE. Primary care physicians can play a crucial role in the counseling of patients regarding testing for prostate can- cer. It has been reported that neither urologists nor radi- ation oncologists provide a broad view to the patient of the strengths and weaknesses of testing and treatment; instead, they focus upon discussing with the patient the kinds of treatment each can provide. 7 This approach, however, is problematic because it does not reflect the current acceptance of surgery, radiation therapy, and watchful waiting as each representing acceptable thera- py. 8–10 Further, this approach may inhibit the perfor- mance of randomized clinical trials necessary to deter- mine the appropriate clinical approach for prostate cancer at its various stages and differentiation. 11 Providing such information to patients is a chal- lenge. Studies on using decision aids to inform patients regarding the risks, benefits, and uncertainties of prostate cancer testing and treatment have provided mixed results. Some studies showed an increase in test- ing after patients have been exposed to decision aids; some showed differential effects depending upon the site of administration of the decision aids; some 54 Hospital Physician February 2001 www.turner-white.com Outcomes-Based Practice Early Detection and Treatment of Prostate Cancer Series Editor: Bryan A. Liang, MD, PhD, JD Case Study and Commentary: Timothy J. Wilt, MD, MPH, and Melissa R. Partin, PhD Dr. Wilt is Associate Professor of Medicine, Department of Medicine, University of Minnesota School of Medicine, Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, Minneapolis, MN. Dr. Partin is a Research Scientist, Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, and Adjunct Assistant Professor, Department of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN. Dr. Liang is the Arthur W. Grayson Distinguished Professor of Law & Medicine, Southern Illinois University School of Law and School of Medicine, Carbondale, IL; Research Council Faculty Fellow, Instituut voor Sociaal Recht, Katholieke Universiteit, Leuven, Belgium; and a member of the Hospital Physician Editorial Board. Dr. Liang is supported by Katholieke Universiteit Leuven Grant No. F/98/084.