Study examines health literacy and shared decision-making in prostate cancer screening

New research examines the dynamics between men’s health literacy, their discussions with their doctors, and their decisions on whether to get tested for prostate-specific antigen (PSA), a potential marker of prostate cancer. The findings are published early online in Cancer, a peer-reviewed journal of the American Cancer Society (ACS).

Controversy exists over PSA testing for prostate cancer because it may lead to overdiagnosis and subsequent over-treatment. In 2012, guidelines recommended against PSA screening for all men, but the most recent guidelines from 2017 state that for men between the ages of 55 to 69 years, physicians and patients should have meaningful discussions concerning PSA screening’s advantages and disadvantages so as to make choices based on shared decision-making.

This approach depends on both physicians’ ability to clearly and accurately explain relatively complex clinical concepts and engage patients in the process, as well as on patients’ ability to understand the information provided. In this respect, health literacy, or the degree to which individuals have the capacity to understand health information and services to make appropriate health decisions, is important.

To better understand the effect of health literacy and shared decision-making on patients’ likelihood of undergoing PSA screening, investigators examined 2016 data from the Behavioral Risk Factor Surveillance System, an annual health survey of a random sample of U.S. adults. The analysis included information representing more than 12 million men aged 50 years or older who reported their last year’s PSA screening status.

Higher health literacy was associated with higher rates of PSA screening, a surprising result given the 2012 guidelines’ recommendation against screening. This finding suggests that men with the highest health literacy may request to undergo PSA testing despite knowledge of the recommendations, or that physicians may be more likely to offer PSA screening to patients with higher health literacy compared with other patients.

The researchers also identified a dynamic interplay between health literacy and shared decision-making. Specifically, in the presence of shared decision-making, patients with higher health literacy were less likely to undergo PSA screening compared with patients with low health literacy.

“This finding should inform the creation and promulgation of shared decision-making guidelines and interventions, specifically when considering patients with low health literacy,” said lead author David-Dan Nguyen, MPH, a research fellow at the Center for Surgery and Public Health (a joint initiative of the Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health), under the supervision of Dr. Jesse Sammon, DO, an assistant professor at Tufts University School of Medicine. Nguyen noted that physicians may also need guidance in assessing patients’ health literacy. “Providers consistently overestimated patients’ health literacy, and this poor accuracy may diminish the providers’ ability to successfully personalize communication with patients and engage them in shared decision-making, especially for patients with the lowest levels of health literacy,” he said.

An accompanying editorial notes that the study provides important information on the relationship between health literacy, shared decision-making, and PSA screening, and notes the findings offer less insight for the character of this dynamic in the general population. “Further prospective investigation into how best to educate and empower vulnerable populations with lower health literacy to make informed decisions is required in order to design effective interventions to improve PSA screening in populations at greatest risk,” the authors wrote.