Decision Making in Prostate-Specific Antigen Screening National Health Interview Survey, 2000 Paul K. J. Han, MD, MA, MPH, Ralph J. Coates, PhD, Robert J. Uhler, MA, Nancy Breen PhD Background: The net benefits and harms of prostate cancer screening with the prostate-specific antigen (PSA) test are uncertain, and professional organizations recommend that physicians discuss these uncertainties with patients before initiating screening. Using a nationally representative sample of men reporting past PSA screening, we aimed to determine the extent to which screening was initiated by physicians and preceded by physician–patient discussions. Methods: Cross-sectional analysis of data from the 2000 National Health Interview Survey; 2676 men aged 40 and older underwent PSA screening and met study inclusion criteria. We analyzed the proportions of men for whom PSA screening was (1) was initiated by the physician versus the patient, and (2) preceded by discussions about the test’s advantages and disadvantages. Results: Overall, 74% (95% CI=71.8 –76.0) of recipients reported that PSA screening was initiated by their physician, and the proportion increased with advancing age, declining health status, lack of family history of prostate cancer, presence of a usual source of medical care, and non-Hispanic ethnicity. Sixty-five percent (95% CI=63.1– 67.1) of screening recipients reported prescreening discussions with their physicians. Discussions were more common with physician-initiated screening than with patient-initiated screening, and among pa- tients reporting a usual source of medical care, non– blue-collar occupation, and black race. Conclusions: Among U.S. men receiving PSA screening, screening is usually initiated by physicians, frequently in men relatively less likely to benefit from it, and often without prior discussion of the test’s advantages and disadvantages. Further examination of the PSA decision- making process among screened and unscreened men is warranted. (Am J Prev Med 2006;30(5):394 – 404) © 2006 American Journal of Preventive Medicine Introduction P rostate cancer is a common malignancy and a major cause of mortality in men in the United States. It accounts for one third of all diagnosed cancers in U.S. men, and represents the second most common cause of male cancer deaths, and the tenth leading cause of reduced life expectancy. 1 In 2005, approximately 232,000 new cases of prostate cancer will be diagnosed in the United States, and approximately 30,000 deaths from prostate cancer will occur. 1 The prevalence and mortality burden of prostate cancer have driven widespread screen- ing with the prostate-specific antigen (PSA) test. 2 At the same time, however, PSA screening has re- mained controversial for several reasons. The PSA test itself has limited accuracy and predictive power, 3–5 and leads to frequent false-positive and false-negative re- sults. Prostate cancer also has a heterogeneous, often indolent, natural history, raising questions about the value of early diagnosis by any means. 6 The substantial gap between the estimated lifetime risk of developing occult prostate cancer in U.S. men (40% or higher) and the estimated lifetime mortality risk (approxi- mately 3%) 7 indicates that most cancers are slow- growing and nonfatal. Thus, prostate cancer screening might cause substantial overdiagnosis, 4,8 rather than real improvements in mortality or morbidity. Finally, the balance of benefits and harms of treating screening- detected prostate cancers is uncertain. Treatments such as radical prostatectomy may reduce prostate cancer mortality in men with early-stage disease 9 ; however, the mortality benefit takes several years to be realized, at the cost of immediate iatrogenic harms that are diffi- cult to estimate precisely, e.g., erectile dysfunction in From the Division of Cancer Control and Population Sciences, National Cancer Institute (Han, Breen), Bethesda, Maryland; and Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (Coates, Uhler), Atlanta, Georgia Address correspondence and reprint requests to: Paul K. J. Han, MD, MA, MPH, Basic and Biobehavioral Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Boulevard, EPN 4097, MSC 7363, Rockville MD 20892-7363. E-mail: hanp@mail.nih.gov. 394 Am J Prev Med 2006;30(5) 0749-3797/06/$–see front matter © 2006 American Journal of Preventive Medicine • Published by Elsevier Inc. doi:10.1016/j.amepre.2005.12.006