CHAPEL HILL, N.C. – Prostate cancer screening is one of the most common decisions men face in primary care, yet many patients make that choice without fully understanding the potential benefits and harms. A new editorial by UNC physician experts argues that shared decision-making should no longer depend on individual clinician effort but instead be built into health care systems.
Published in The Journal of Urology, the editorial calls for health systems to take responsibility for ensuring that patients are meaningfully involved in decisions about prostate‑specific antigen (PSA) screening.
“Millions of men make decisions every year about prostate cancer screening without meaningful conversations about risks and benefits,” said Adam Goldstein, MD, MPH, Elizabeth and Oscar Goodwin Distinguished Professor in the UNC Department of Family Medicine. “That is more than a gap in care; it is a system failure.”
Goldstein also serves as Director of Tobacco Intervention Programs at the UNC School of Medicine, where his work has focused on building health‑system approaches that reliably deliver evidence‑based tobacco treatment and prevention services. He says prostate cancer screening presents a similar challenge.
A decision with real tradeoffs
PSA screening can reduce prostate cancer deaths for some men, but it also carries risks, including false‑positive results, unnecessary biopsies, and overtreatment. Because outcomes vary based on age, family history, race, and personal values, national guidelines recommend that screening decisions be made using shared decision making.
Shared decision making involves clinicians and patients discussing both the benefits and potential harms associated with screening, along with the patient’s individual risk and preferences. However, studies show that fewer than one in three men who receive PSA screening recall having those discussions.
Impact on equity and trust
The editorial emphasizes that inconsistent shared decision making has important equity implications. Black men have significantly higher rates of prostate cancer and more than double the mortality compared with White men, yet they are less likely to report conversations about screening risks and benefits.
“When patients are not invited into decisions, inequities deepen and trust in the healthcare system can erode,” Goldstein said. He noted that similar patterns have been well documented in tobacco treatment, where system‑level approaches have been essential to reducing disparities and improving outcomes.
Moving beyond individual effort
Rather than framing shared decision making as something clinicians should do when time allows, the authors argue it should be treated as a high‑reliability process, similar to medication safety or surgical timeouts.
“We have too often treated shared decision making around prostate cancer screening as something individual clinicians should do when they have time,” Goldstein said. “In reality, it must be built into the system to work consistently.”
The editorial calls for practical, system‑level solutions, including automatically identifying eligible patients, embedding decision aids into electronic health records, using structured documentation, and monitoring whether shared decision making is delivered reliably.
Shared commitment across specialties
Marc Bjurlin, DO, MSc, FACOS, associate professor of urology at the UNC School of Medicine and a urologic oncologist at UNC Lineberger Comprehensive Cancer Center, emphasized that shared decision making is essential given the balance of benefit and potential harm.
“Prostate cancer screening involves real tradeoffs, which makes shared decision making essential, not optional,” Bjurlin said.
Bjurlin’s clinical and research work has also focused on the role of smoking and other modifiable risk factors in urologic cancers, including prostate and bladder cancer. He notes that addressing cancer risk through prevention, screening, or treatment requires health systems that consistently support informed, patient‑centered decisions.
Looking ahead
The authors conclude that improving prostate cancer screening is not about ordering more or fewer tests, but about ensuring patients are informed partners in the decision.
“Shared decision making is how we navigate uncertainty in a way that is ethical, patient‑centered, and equitable,” Goldstein said. “Health systems have a responsibility to make that happen.”
Read the article, “Shared Decision Making for Prostate Cancer Screening is a System Responsibility,” (paid) here.