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Comment & Response
September 23, 2013

If Less Is More, Which Outcomes Should Be Presented in Facilitating Prostate Cancer Screening Decision Making?

Author Affiliations
  • 1Minneapolis Veterans Affairs Health Care System, Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota
JAMA Intern Med. 2013;173(17):1656-1657. doi:10.1001/jamainternmed.2013.8155

To the Editor The study by Pignone and colleagues,1 which found that the relative importance patients assign to specific prostate cancer screening outcomes depends on the method used to summarize them, provides sobering documentation of how sensitive patient opinions can be to differences in presentation. Given previous research documenting that less can be more in communicating complex risk information to patients,2 the authors appropriately limit the number of outcomes presented in their values clarification exercises to 4. However, it is not clear why they selected these particular outcomes over other potentially relevant outcomes. We recognize that the focus of the study by Pignone et al1 was not to identify which outcomes to highlight in a decision aid, but rather to evaluate whether the type of values clarification exercise used affects the judgments derived from this process. However, the selection of outcomes highlighted may have had a large effect on the overall preference for screening observed and may very well be the most critical issue to address in applying the findings from their study to the design of future decision aids. If presenting all the potential outcomes would be overwhelming for patients, we believe that the most critical outcomes to present are those relating directly to morbidity and mortality. In the study by Pignone et al,1 2 of the outcomes included in the values clarification exercises meet this criteria (the chance of developing impotence and incontinence as a result of screening and the chance of dying of prostate cancer). The remaining 2 outcomes do not (the chance of being diagnosed as having prostate cancer and the chance of requiring a prostate biopsy). For these outcomes, patients must infer the morbidity and mortality implications of each state. In a recent review of the literature, the US Preventive Services Task Force estimated that the number of men who will avoid a prostate cancer death through screening is between 0 and 1 per 1000 men screened.3 However, they found no evidence of an all-cause mortality benefit and estimated that 5 men in 1000 would experience a life-threatening complication (ie, blood clot, myocardial infarction, infection-related hospitalization) from follow-up procedures. If less is more, we believe future decision aids should find ways to incorporate information on these serious complications. Although less prevalent than some of the more commonly highlighted harms of prostate cancer screening (eg, false-positive biopsy results, treatment-related impotence and incontinence), they are more serious and more likely to occur than a survival benefit from screening.

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