Andrew M. D. Wolf

In 2009, the American Cancer Society (ACS) Prostate Cancer Advisory Committee began the process of a complete update of recommendations for early prostate cancer detection. A series of systematic evidence reviews was conducted focusing on evidence related to the early detection of prostate cancer, test performance, harms of therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening. The results of the systematic reviews were evaluated by the ACS Prostate Cancer Advisory Committee, and deliberations about the evidence occurred at committee meetings and during conference calls. On the basis of the evidence and a consensus process, the Prostate Cancer Advisory Committee developed the guideline, and a writing committee drafted a guideline document that was circulated to the entire committee for review and revision. The document was then circulated to peer reviewers for feedback, and finally to the ACS Mission Outcomes Committee and the ACS Board of Directors for approval. The ACS recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources. Patient decision aids are helpful in preparing men to make a decision whether to be tested.

BACKGROUND: Because of the many uncertainties surrounding screening for prostate cancer, authorities recommend that patients be involved in the screening decision. OBJECTIVE: To determine the impact of informed consent on patient interest in undergoing prostate-specific antigen (PSA) screening. METHODS: Men 50 years or older with no prior PSA testing and no history of prostate cancer presenting to 1 of 4 university-affiliated primary care practices were eligible for enrollment. Patients were randomized to receive either a scripted informational intervention simulating an informed consent presentation (intervention group, n = 103) or a single sentence about the PSA (control group, n = 102). The main outcome measure was patient interest in undergoing PSA screening measured on a 5-point Likert scale. RESULTS: Patients who received the informational intervention were significantly less interested in undergoing PSA screening than controls (mean difference in interest, 0.8 on 5-point scale, P < .001). Informed patients were much less likely to indicate high interest in screening (odds ratio, 0.34; 95% confidence interval, 0.19-0.60; P < .001). In a multivariate model, family history of prostate cancer was associated with increased interest and advancing age with decreased interest in PSA screening, but the informational intervention remained the strongest predictor of interest. CONCLUSIONS: Among primary care patients of predominantly lower socioeconomic status, those who received informed consent were significantly less interested in PSA screening than those who did not. For physicians who offer the PSA as a screening test, this finding highlights the importance of apprising patients of the associated benefits, burdens, and uncertainties and allowing them to participate in the screening decision.

Identifying mechanisms through which individual differences in reward learning emerge offers an opportunity to understand both a fundamental form of adaptive responding as well as etiological pathways through which aberrant reward learning may contribute to maladaptive behaviors and psychopathology. One candidate mechanism through which individual differences in reward learning may emerge is variability in dopaminergic reinforcement signaling. A common functional polymorphism within the catechol-O-methyl transferase gene (COMT; rs4680, Val(158) Met) has been linked to reward learning, where homozygosity for the Met allele (linked to heightened prefrontal dopamine function and decreased dopamine synthesis in the midbrain) has been associated with relatively increased reward learning. Here, we used a probabilistic reward learning task to asses response bias, a behavioral form of reward learning, across three separate samples that were combined for analyses (age: 21.80 ± 3.95; n = 392; 268 female; European-American: n = 208). We replicate prior reports that COMT rs4680 Met allele homozygosity is associated with increased reward learning in European-American participants (β = 0.20, t = 2.75, P < 0.01; ΔR(2) = 0.04). Moreover, a meta-analysis of 4 studies, including the current one, confirmed the association between COMT rs4680 genotype and reward learning (95% CI -0.11 to -0.03; z = 3.2; P < 0.01). These results suggest that variability in dopamine signaling associated with COMT rs4680 influences individual differences in reward which may potentially contribute to psychopathology characterized by reward dysfunction.

BACKGROUND: Use of the prostate-specific antigen (PSA) as a screening test remains highly controversial, particularly in older men. This study was undertaken to assess the impact of information on the preferences of older men for such screening. METHODS: The elderly cohort (age > or = 65 years) of a larger randomized trial was studied to determine the effect of a 3-minute scripted informational intervention on primary care patients' interest in PSA screening and on potential predictors of screening interest. RESULTS: Informed patients were significantly less interested in screening than were uninformed patients (p = .006). Informed patients considered PSA screening to be significantly less efficacious than did uninformed patients (p = .004), but among both uninformed and informed patients, perceived efficacy correlated with interest in screening (multivariate OR 2.3, 95% CI 1.5-3.8 for uninformed patients; OR 2.2, 95% CI 1.3-3.9 for informed patients). Perceived seriousness of prostate cancer predicted interest in screening among uninformed patients (OR 1.8, 95% CI 1.3-2.6), but not among informed patients. Informed patients who were married were less interested in screening than those who were single, divorced, or widowed (OR 0.3, 95% CI .08-0.9). Marital status did not predict screening interest among uninformed patients. CONCLUSIONS: Involving elderly patients in the decision whether to screen with the PSA by providing them with information leads to a significant reduction in interest in such screening. Factors that appear to influence the screening preferences of informed elderly patients include perceived efficacy of screening and marital status, whereas uninformed patients are more likely to weigh the perceived seriousness of prostate cancer in their screening decision.