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Physician Decision Making in Testing for Prostate Cancer

Paul Sorum
Albany, NY

Why do so many primary care physicians routinely order prostate specific antigen (PSA) tests on their asymptomatic male patients over 50?

I have participated over the past year in a study of judgment and decision making about testing for prostate cancer in collaboration with Junseop Shim and Tom Stewart in Albany and with Gérard Chasseigne, his student (Sylvie Bonnin), and his physician (Joel Cogneau) in Tours, France. Junseop describes in his submission to the Brunswik newsletter the methodology of the study and his particular focus on physicians' perceptions of the guidelines.

Dr. Cogneau and I were primarily interested in trying to answer the question of why physicians routinely order PSA's in spite of the recommendations against this of their specialty groups. The study was designed to test seven hypothetical explanations: 1) that physicians who test routinely are not aware of the evidence-based specialty recommendations (but are likely to be aware of the position of the American Cancer Society); 2) that these physicians are deferring to patients' requests or demands (which are fueled by the media); 3) that they think that PSA tests provide very useful diagnostic information; 4) that they think that treatment of asymptomatic prostate cancer is more beneficial than the evidence suggests; 5) that they would greatly regret it if they did not order a PSA and the patient was subsequently found to have an advanced cancer; 6) that they fear that such a patient might sue them for malpractice; and 7) that they are uncomfortable with uncertainty (and hope to reduce uncertainty through testing).

We found evidence to support, to some degree, all of our hypotheses (with the exception of #6); the high rate of ordering PSAs is associated with a multiplicity of factors. Not yet tested is the hypothesis that physicians display consistency, in the sense that those who order more tests will tend to score more highly on all or most of the explanatory factors.

In comparing groups, French primary care physicians, on the whole, seemed to be less aggressive than American ones in trying to find prostate cancer in asymptomatic patients, and U.S. family practitioners less than general internists. These group differences were reflected in differences in the explanatory factors and are consistent with findings in other studies.

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