Does Consistency Predict Accuracy of Beliefs?: Economists Surveyed About PSA

Subjective beliefs and behavior regarding the Prostate Specific Antigen (PSA) test for prostate cancer were surveyed among attendees of the 2006 meeting of the American Economic Association. Logical inconsistency was measured in percentage deviations from a restriction imposed by Bayes’ Rule on pairs of conditional beliefs. Economists with inconsistent beliefs tended to be more accurate than average, and consistent Bayesians were substantially less accurate. Within a loss function framework, we look for and cannot find evidence that inconsistent beliefs cause economic losses. Subjective beliefs about cancer risks do not predict PSA testing decisions, but social influences do.logical consistency, predictive accuracy, elicitation, non-Bayesian, ecological rationality

Does consistency predict accuracy of beliefs?: Economists surveyed about PSA

Subjective beliefs and behavior regarding the Prostate Specific Antigen (PSA) test for prostate cancer were surveyed among attendees of the 2006 meeting of the American Economic Association. Logical inconsistency was measured in percentage deviations from a restriction imposed by Bayes’ Rule on pairs of conditional beliefs. Economists with inconsistent beliefs tended to be more accurate than average, and consistent Bayesians were substantially less accurate. Within a loss function framework, we look for and cannot find evidence that inconsistent beliefs cause economic losses. Subjective beliefs about cancer risks do not predict PSA testing decisions, but social influences do.logical consistency, predictive accuracy, elicitation, non-Bayesian, ecological rationality

Nature-based supportive care opportunities: A conceptual framework

Objective: Given preliminary evidence for positive health outcomes related to contact with nature for cancer populations, research is warranted to ascertain possible strategies for incorporating nature-based care opportunities into oncology contexts as additional strategies for addressing multidimensional aspects of cancer patients’ health and recovery needs. The objective of this study was to consolidate existing research related to nature-based supportive care opportunities and generate a conceptual framework for discerning relevant applications in the supportive care setting. Methods: Drawing on research investigating nature-based engagement in oncology contexts, a two-step analytic process was used to construct a conceptual framework for guiding nature-based supportive care design and future research. Concept analysis methodology generated new representations of understanding by extracting and synthesising salient concepts. Newly formulated concepts were transposed to findings from related research about patient-reported and healthcare expert-developed recommendations for nature-based supportive care in oncology. Results: Five theoretical concepts (themes) were formulated describing patients’ reasons for engaging with nature and the underlying needs these interactions address. These included: connecting with what is genuinely valued, distancing from the cancer experience, meaning-making and reframing the cancer experience, finding comfort and safety, and vital nurturance. Eight shared patient and expert recommendations were compiled, which address the identified needs through nature-based initiatives. Eleven additional patient-reported recommendations attend to beneficial and adverse experiential qualities of patients’ nature-based engagement and complete the framework. Conclusions: The framework outlines salient findings about helpful nature-based supportive care opportunities for ready access by healthcare practitioners, designers, researchers and patients themselves

A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN)

Review methods: In the quantitative review, data on relevant outcomes, patient populations, intervention type and study quality were extracted. Quality appraisal was conducted independently by two reviewers using the Cochrane risk of bias tool. Meta-analysis was conducted to compare the effects of interventions in male, female and mixed-sex groups. In the metaethnography, study details, participant quotes (first-order constructs) and study authors’ themes/concepts (second-order constructs) were extracted. Quality appraisal was conducted independently by two reviewers using the Critical Appraisal Skills Programme tool. Data were synthesised according to a metaethnography approach. Third-order interpretations/constructs were derived from the extracted data and integrated to generate a ‘line-of-argument’ synthesis. Results: Forty RCTs of self-management support interventions in male-only samples, and 20 RCTs where an analysis by gender was reported, were included in the quantitative review. Meta-analysis suggested that interventions including physical activity, education and peer support have a positive impact on quality of life in men, and that men may derive more benefit than women from them, but there is currently insufficient evidence to draw definitive conclusions. Thirty-eight qualitative studies relevant to men’s experiences of, and perceptions of, self-management support were included in the qualitative review. The metaethnography identified four concepts: (1) need for purpose; (2) trusted environments; (3) value of peers; and (4) becoming an expert. Findings indicated that men may feel less comfortable engaging in support if it is perceived to be incongruous with valued aspects of masculine identities. Men may find support interventions more attractive when they have a clear purpose, are action-oriented and offer practical strategies that can be integrated into daily life. Support delivered in an environment that offers a sense of shared understanding can be particularly appealing to some men. Conclusions: Health professionals and those involved in designing interventions may wish to consider whether or not certain components (e.g. physical activity, education, peer support) are particularly effective in men, although more research is needed to fully determine and explore this. Interventions are most likely to be accessible and acceptable to men when working with, not against, valued aspects of masculine identities

Prostate cancer screening in primary care: Doctors’ perspectives on prostate-specific antigen (PSA) screening of asymptomatic men in Australia and the United Kingdom

Screening for prostate cancer is a highly debated public health issue. The evidence base is contested, the prostate-specific antigen (PSA) test as a screening technology is limited, no medical body recommends a population screening program for prostate cancer screening, local authorities differ in the advice they offer on the value of PSA screening in clinical care, and the substantial harms associated with PSA screening are well documented. Decisions about PSA screening most commonly occur in consultation with a general practitioner (GP). This qualitative study was designed to explain how GPs understand, reason about, and use the PSA test to screen men for prostate cancer risk in primary care. Australia and the United Kingdom draw on the same evidence base for prostate cancer screening yet have notably different rates of PSA screening; they are the two locations of this research study. In this thesis I report on GP perspectives on PSA screening. Methods: This is an empirical study using grounded theory methodology. Data were generated from in-depth interviews with GPs in Australia and the United Kingdom, who make decisions about using or not using the PSA test as a screening tool. Analysis was developed through transcript coding and detailed memo writing, using constant comparison to develop insight and connections between concepts. The overall aim of the study was to gain an in-depth understanding of how and why clinicians use the PSA test to screen for prostate cancer in primary care. Main findings: This grounded theory study found that for Australian GPs on the frontline, decision making about PSA screening is extremely difficult and complex. There was extensive variation in the clinicians’ accounts of their screening behaviour. Different motivations (values and goals) of GPs, context of the clinic and specific clinical interactions, opportunity to trust, and responses to uncertainty, were central explanations for varied practice. GPs intuitively and/or explicitly drew from multiple, potentially 3 conflicting, types of knowledge (including that from the research evidence) - developed over time – to guide their screening decisions. The study included UK GPs as a comparison case to examine the place of past and present screening policy, and healthcare system structure and organisation in influencing and incentivising particular ways of practicing. The UK experience demonstrates that Australian screening practices are not inevitable – things can be done differently. Some Australian clinicians in this study experienced significant emotional and cognitive burden, as a result of making screening decisions under challenging conditions. The empirical chapters of the thesis focus on four key issues: managing the potential for overdiagnosis, responding to uncertainty, practice and policy context, and communicating about PSA screening. The Discussion chapter draws these findings together into a new explanatory model of GPs’ decision making about PSA screening. Conclusion: This research provides an in-depth comparative analysis of important drivers of prostate cancer screening reported from the perspective of GPs in two locations with diverse screening rates. The model produced provides an explanation of the complex and varied process of PSA screening in the two jurisdictions. Policy continues to evolve and attract substantial debate in this field in Australia. Given that past attempts to intervene in PSA screening practice in Australia seem to have had limited effect, a new approach that better reflects the complexity of this issue, including the range of drivers of current practice, seems warranted. These findings offer useful empirical guidance for future policy and practice, grounded in the experiences of clinicians

Experiences of signs and symptoms among men with advanced prostate cancer

Background: In the past decade, thanks to improved treatment options, many men with metastatic prostate cancer now survive longer than they would have before. The PSA value is often followed during the entire disease trajectory as a sign, but in late phases, symptom burden, quality of life (QoL), and/or psycho-social factors are assigned more importance in treatment decisions and evaluations. From the men´s perspective the change of the clinical importance of the PSA value in assessment of treatment effect and as a sign of disease progression may not be obvious and they may therefore experience distress about values with little clinical relevance. When having a life-limiting disease, symptom management also plays a vital role in the balance between prolonging life and QoL but there are few studies describing symptom burden in a real-world situation in these men. In order to support these men, it is important to gain an understanding from the men‘s perspective of their experiences and interpretations of signs and symptoms. Aim: The overall aim of this thesis project was to study signs and symptoms in relation to progression of the disease in men with advanced prostate cancer. The underlying hypothesis was that signs and symptoms may be experienced as distressing as markers of potential progression influencing QoL in advanced prostate cancer. Methods: Both quantitative and qualitative research approaches were used. The thesis is based on data from two different overall projects: a survey sent to all members of the Swedish Prostate Cancer Federation (SPCF) and the PROstate Cancer-Experiences and Expectations During treatment (PROCEED) project. In study I descriptive statistics and logistic regression analysis were used to analyze self-reported questionnaires regarding distress and PSA values. In study II content analysis was used to analyze longitudinal interview data. In study III, descriptive- and linear regression analysis were used to describe symptoms, symptom dimensions and symptom burden, and to investigate associations between QoL and symptom burden. In study IV, descriptive statistics regarding symptoms, symptom dimensions and symptom burden were described at five timepoints. To analyze changes over time for symptom burden, linear mixed modeling was applied. Results: Men with advanced prostate cancer experience an uncertain illness situation when living with a life-limiting disease. They used signs and symptoms to make sense of their situation. Many of the men were preoccupied with the PSA values as the sign that they described as most important. Over time, as some men experienced more and more symptoms, the importance of the PSA values decreased, and the symptoms and consequences of the symptoms became more important to the men. Some men had a lot of symptoms when starting treatment, mostly physical and not so often psychological symptoms. Except for distress in relation to increased levels of PSA, many men did not report feelings such as worry or fear, even if most of them knew that they had a limited time to live. The different symptoms varied in dimensions of frequency, severity and distress, and sexual problems were most reported, followed by pain and lack of energy. The physical symptoms worsened significantly over time while psychological symptoms and number of symptoms did not. Conclusion: When living with progressing advanced prostate cancer, an uncertain illness situation was described. In this uncertainty, signs and symptoms were used to make sense of their situation. To understand the men’s interpretations of signs and symptoms is important since misunderstandings or misinterpretations may cause unnecessary distress and reduced QoL in this late phase of the disease. The men experienced mostly physical symptoms, which also worsened over time. Sexual problems were common and may need to be acknowledged more, even if the underlying causes is difficult to resolve, support in handling the problem could be beneficial. Pain and fatigue were also common and were experienced as distressing, and some symptoms may have been insufficiently managed. These findings may help health care professionals to understand the disease from the men’s perspective. Enhancing QoL is also the main goal for palliative care and a palliative approach early in the disease trajectory in the oncology outpatient setting could benefit these men

An empirical ethics analysis of breast cancer screening in Australia

Breast screening is controversial. Despite many supporters and a large evidence base, some experienced breast screening experts disagree with selected policies and practices. I sought to examine the reasoning of people who have influenced breast screening in Australia. I used an empirical ethics approach, combining empirical study with theoretical analysis. I interviewed Australians with expertise and influence in breast screening across a range of professional roles. I found that participants drew on values as well as evidence when talking and reasoning about breast screening. Participants expressed a range of interpretations and prioritisations for each value and experts’ disagreements were based, at least in part, on these differences. Experts did not always acknowledge the role of values in shaping their views or recognise different ways of conceptualising or prioritising values. I recommend including values in decision making for breast screening policy and practice. I provide guidance about formats for values based discussions. I conclude that values play an important but often unrecognised role in shaping breast screening policy and practice, and propose regular review of values to deliver breast screening in the most ethically sound manner