Shared decision-making conversations about prostate cancer screening are happening in fewer than 7% of family medicine visits, even though research shows these discussions significantly increase the likelihood of informed screening choices. A study published in the Southern Medical Journal found a stark gap between current practice and recommended guidelines, raising questions about how well doctors are preparing patients for one of medicine's most debated screening decisions.

What Is Shared Decision-Making in Prostate Cancer Screening?

Shared decision-making (SDM) is a conversation between a doctor and patient that weighs the potential benefits and harms of prostate cancer screening before any test is ordered. For prostate cancer, this typically involves discussing the prostate-specific antigen (PSA) blood test, which measures a protein produced by the prostate gland. The conversation should help patients understand that while screening can catch cancer early, it may also lead to false alarms, unnecessary biopsies, or overtreatment of slow-growing cancers that might never cause harm.

Researchers from the Medical University of South Carolina reviewed medical records of 600 men aged 45 to 69 who visited an academic family medicine practice between 2019 and 2020. The findings were striking: documented SDM conversations occurred for only 7.3% of Black men and 5.3% of non-Black men.

How Much Does Shared Decision-Making Actually Change Screening Rates?

The study revealed a powerful connection between having an SDM conversation and actually getting screened. Among men who had documented shared decision-making discussions, 71.8% underwent PSA screening. In contrast, only 35.6% of men without such conversations were screened. The difference was even more pronounced among Black men: 85.0% of those with SDM conversations received screening, compared to 35.7% without.

This suggests that when doctors take time to discuss screening with patients, men are more likely to make an active choice about whether to proceed, rather than defaulting to either automatic testing or avoidance.

"One of the biggest takeaways was the surprisingly low rate of documented shared decision-making conversations. The other key finding was that when those conversations were documented, screening was much more likely to occur," said Dr. Nicholas Shungu, from the Medical University of South Carolina.

Dr. Nicholas Shungu, Medical University of South Carolina

Why Are These Conversations So Rare?

The study did not explore the reasons behind the low documentation rates, but several factors likely contribute. Time constraints in busy family medicine practices, lack of training in SDM techniques, and uncertainty about screening guidelines may all play a role. Additionally, some doctors may assume patients want screening without asking, or conversely, may avoid the topic altogether due to controversy surrounding PSA testing.

The gap is particularly important because prostate cancer screening remains one of the most contentious topics in preventive medicine. Major health organizations have different recommendations: some suggest screening discussions for men in their 50s, while others recommend starting conversations earlier for Black men and those with a family history of prostate cancer, due to higher risk.

How to Prepare for a Prostate Cancer Screening Conversation

If you're a man considering prostate cancer screening, here are steps you can take to have a more informed discussion with your doctor:

• Ask about your risk factors: Discuss your age, race, family history of prostate cancer, and any symptoms you may be experiencing before deciding whether screening is right for you.
• Request a shared decision-making conversation: Explicitly ask your doctor to discuss both the benefits and potential harms of PSA testing, including the risk of false positives and overtreatment.
• Understand what a PSA test measures: Learn that the prostate-specific antigen test detects a protein in the blood, but elevated levels don't always mean cancer and can result from benign prostate conditions or infections.
• Discuss next steps if results are abnormal: Ask what happens if your PSA is elevated, including whether a biopsy would be recommended and what that procedure involves.
• Bring written questions: Prepare a list of concerns or questions ahead of time to ensure your doctor addresses your specific worries about screening.

The Broader Problem: Tumor Markers Versus True Screening

Beyond the conversation gap, there's another important distinction patients should understand. PSA testing is sometimes promoted as a general cancer screening tool, but experts caution against confusing tumor markers with evidence-based screening. Dr. Saneya Pandrowala, a gastrointestinal and hepatopancreatic oncologist at KIMS Hospitals in Thane, India, emphasizes that routine annual tumor marker testing is not recommended for most healthy people without symptoms or significant risk factors.

"For most healthy adults with no symptoms or significant family history, routine annual tumor marker testing is not recommended," explained Dr. Saneya Pandrowala, Consultant in GI and HPB Oncosurgery at KIMS Hospitals.

Dr. Saneya Pandrowala, Consultant, GI and HPB Oncosurgery, KIMS Hospitals

Current international guidelines do not support using blood tests like PSA as a general cancer-screening tool for the general population because they have not been shown to reduce cancer-related deaths in healthy people without risk factors. Instead, tumor markers play a different role: they are far more useful in people who already have a diagnosed cancer, where they help monitor treatment response, detect recurrence, or assess disease progression.

The key takeaway is that PSA and other tumor markers can be elevated in many non-cancerous conditions, including infections, inflammation, liver disease, and even smoking. Additionally, normal results do not guarantee the absence of cancer, and many people with early-stage cancers may have completely normal tumor marker levels.

What Should Patients Actually Do?

The research underscores the importance of individualized, informed decision-making rather than routine screening for all men. If you're considering prostate cancer screening, the conversation with your doctor should be tailored to your specific age, race, family history, and personal values regarding the trade-offs between early detection and the risks of false positives and overtreatment.

The low rate of documented shared decision-making conversations suggests that many men are not getting the information they need to make truly informed choices about prostate cancer screening. By asking your doctor for a shared decision-making discussion and understanding the nuances of PSA testing, you can take a more active role in your own health care decisions.