Should there be informed decision-making for prostate cancer screening? An analysis of preference sensitivity

Background Almost all national guidelines groups recommend that individual men make an informed personal decision about whether to be screened for prostate cancer. This implies the decision to undergo prostate-specific antigen (PSA) testing is preference sensitive; that is, whether the expected utility of screening is higher or lower than that of no screening can vary depending on a man's preferences (“utilities”) for downstream health states such as urinary incontinence. Methods We reviewed the literature to find evidence on whether PSA screening is indeed a preference-sensitive decision. Results We found that preference sensitivity was routinely asserted without providing any evidence. Some authors pointed to studies of PSA decision aids, but there is no logical link between a decision aid changing a decision and that decision being preference sensitive. The major modeling study on PSA screening found higher expected utility for PSA screening irrespective of how a man might feel about the side-effects of treatment. One study did find that while PSA screening was generally favored, expected utility was fractionally lower in a small subgroup, but the difference was extremely small, and would not be negative with recent changes to PSA screening pathways. Conclusion The assumption underlying informed choice policies—PSA screening is a preference-sensitive decision—is not supported by the literature. Men should be provided with clear information about and give consent for PSA testing, but preference elicitation as part of shared decision-making is not indicated.