At the University of North Carolina, physician experts have published a call to action in The Journal of Urology: stop leaving prostate cancer screening decisions to chance, and build them into the system itself. The insight cuts to the heart of modern medicine's most persistent blind spot — that good care often depends on individual clinician virtue rather than structural reliability.
The problem is stark. Millions of men make decisions about prostate-specific antigen (PSA) screening every year in primary care, yet fewer than one in three recall having a meaningful conversation about what screening actually means. PSA testing can reduce prostate cancer deaths for some men, but the path is lined with tradeoffs: false positives, unnecessary biopsies, and overtreatment become real possibilities depending on a man's age, family history, race, and personal values. When patients don't understand these consequences before a test is ordered, they're making choices blind.
"That is more than a gap in care; it is a system failure," said Adam Goldstein, MD, MPH, Elizabeth and Oscar Goodwin Distinguished Professor in the UNC Department of Family Medicine and Director of Tobacco Intervention Programs at the UNC School of Medicine. Goldstein's previous work building health systems that reliably deliver evidence-based tobacco treatment gave him a template: shared decision-making — where clinicians and patients discuss both benefits and harms alongside individual risk and preferences — can't be left to happenstance.
The equity stakes run deep. Black men experience 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 aren't invited into decisions, Goldstein emphasizes, inequities deepen and trust in the health care system erodes. This pattern mirrors what researchers have documented in tobacco treatment, where system-level approaches proved essential to reducing disparities.
The editorial's core argument amounts to a reframing: treat shared decision-making around prostate cancer screening not as something clinicians squeeze in when time allows, but as a high-reliability process — like medication safety protocols or surgical timeouts. The authors call for practical, system-level solutions that don't require heroic individual effort: automatically identifying eligible patients, embedding decision aids directly into electronic health records, using structured documentation to track conversations, and monitoring whether shared decision-making is actually being delivered.
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, underscored why this matters clinically. "Prostate cancer screening involves real tradeoffs, which make shared decision making essential, not optional," he said. Bjurlin's own research focuses on modifiable risk factors in urologic cancers — the kinds of prevention and treatment decisions that demand informed, patient-centered thinking rather than rote protocol.
The UNC physicians aren't arguing for more or fewer PSA tests. They're arguing that men deserve to understand what screening means before they consent to it, and that health systems have an obligation to make that understanding routine, not exceptional. It's a vision of medicine where good decisions flow from structure, not just goodwill.