Educational level and first-time PSA testing in general practice

Socioeconomic inequality in prostate cancer diagnostics, primary treatment, rehabilitation, and mortality in Sweden

We designed a nationwide study to investigate the association between socioeconomic factors (household income and education) and different aspects of prostate cancer care, considering both individual- and neighbourhood-level variables. Data were obtained from Prostate Cancer data Base Sweden (PCBaSe), a research database with data from several national health care registers including clinical characteristics and treatments for nearly all men diagnosed with prostate cancer in Sweden. Four outcomes were analysed: use of pre-biopsy magnetic resonance imaging (MRI) in 2018-2020 (n = 11,843), primary treatment of high-risk non-metastatic disease in 2016-2020 (n = 6633), rehabilitation (≥2 dispensed prescriptions for erectile dysfunction within 1 year from surgery in 2016-2020, n = 6505), and prostate cancer death in 7770 men with high-risk non-metastatic disease diagnosed in 2010-2016. Unadjusted and adjusted odds and hazard ratios (OR/HRs) with 95% confidence intervals (CIs) were calculated. Adjusted odds ratio (ORs) comparing low versus high individual education were 0.74 (95% CI 0.66-0.83) for pre-biopsy MRI, 0.66 (0.54-0.81) for primary treatment, and 0.82 (0.69-0.97) for rehabilitation. HR gradients for prostate cancer death were significant on unadjusted analysis only (low vs. high individual education HR 1.41, 95% CI 1.17-1.70); co-variate adjustments markedly attenuated the gradients (low vs. high individual education HR 1.10, 95% CI 0.90-1.35). Generally, neighbourhood-level analyses showed weaker gradients over the socioeconomic strata, except for pre-biopsy MRI. Socioeconomic factors influenced how men were diagnosed with prostate cancer in Sweden but had less influence on subsequent specialist care. Neighbourhood-level socioeconomic data are more useful for evaluating inequality in diagnostics than in later specialist care.

Prostate Cancer Screening Uptake in Transgender Women

Importance

There is no consensus in prostate-specific antigen (PSA) screening guidelines regarding transgender women despite their known prostate cancer risk.

Objective

To identify factors associated with recent (within the last 2 years) PSA screening in transgender women compared with cisgender men.

Design, Setting, and Participants

This case-control study used data from the 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) surveys to characterize rates of PSA screening for prostate cancer within the past 2 years and multivariable logistic regressions to characterize factors associated with recent screening among transgender women. The BRFSS program of the Centers for Disease Control and Prevention annually surveys over 400 000 US adults on behavioral risk factors, chronic illnesses, and use of preventive services. Respondents to the BRFSS who were cisgender men or transgender women 40 years or older and who had complete PSA testing responses and no prostate cancer history were included; 313 transgender women and 138 937 cisgender men met inclusion criteria. Matching was performed by age, race and ethnicity, educational level, employment, annual income, survey year, and cost barriers to care. Data were collected on November 2, 2022, and analyzed from November 2, 2022, to December 3, 2023.

Main Outcomes and Measures

Rates of and factors associated with recent PSA screening in transgender women.

Results

Among the 1275 participants included in the matched cohort (255 transgender women and 1020 cisgender men; 570 [44.7%] aged 55-69 years), recent PSA screening rates among transgender women and cisgender men aged 55 to 69 were 22.2% (n = 26) and 36.3% (n = 165), respectively; among those 70 years and older, these rates were 41.8% (n = 26) and 40.2% (n = 98), respectively. In the matched cohort, transgender women had lower univariable odds of recent screening than cisgender men (odds ratio [OR], 0.65 [95% CI, 0.46-0.92]; P = .02). In a hierarchical regression analysis adding time since the last primary care visit, effect size and significance were unchanged (OR, 0.61 [95% CI, 0.42-0.87]; P = .007). After adding whether a clinician recommended a PSA test, there was no statistically significant difference in odds of screening between transgender women and cisgender men (OR, 0.83 [95% CI, 0.45-1.27]; P = .21). The results were further attenuated when clinician-led discussions of PSA screening advantages and disadvantages were added (OR, 0.87 [95% CI, 0.47-1.31]; P = .32). In a multivariable logistic regression among transgender women, having a recommendation for PSA testing was the factor with the strongest association with recent screening (OR, 12.40 [95% CI, 4.47-37.80]; P < .001).

Conclusions and Relevance

In this case-control study of one of the largest cohorts of transgender women studied regarding PSA screening, the findings suggest that access to care or sociodemographic factors were not principal drivers of the screening differences between transgender women and cisgender men; rather, these data underscore the clinician's role in influencing PSA screening among transgender women.

Employment status among cancer survivors in a Late Effects Clinic in Denmark

PURPOSE

This study aims to investigate changes in employment status among disease-free working-age cancer survivors (CSs) with late effects from diagnosis to their first meeting in the Late Effects Clinic (LEC) and investigate associated patient-reported outcomes of reduced employment status.

METHODS

Retrospective analysis of a cohort of CSs followed in a LEC at a single institution from January, 2022, to March, 2023. Working-age CSs with no current evidence of active cancer were included in this study. CSs completed a baseline questionnaire (EORTC QLQ-SURV100) before their initial consultation. Reduced employment status was defined as transition from being in paid work at diagnosis to working fewer hours or not at all at the first visit. Multivariate linear regression analysis was used.

RESULTS

A total of 119 CSs with diverse cancer types with a mean age of 51 years (range 26 to 70) were included in this study. Eighty percent were female. Of 93 CSs in paid work at diagnosis, 66 (71%) have reduced employment status. Reduced employment status was associated with lower role functioning score (β = -12.3, p = 0.046), higher loss of income score (β = 35.1, p = 0.001), and lower Global health status score (β = - 8.3, p = 0.05).

CONCLUSIONS

This study shows that the majority of CSs seen in the LEC have reduced employment status. This is associated with impaired quality of life.

IMPLICATIONS FOR CANCER SURVIVORS

Identifying and treating late effects early in cancer survivorship are important to secure CSs' labour market attachment and, thus, their financial and social well-being.

Ethical Principles in the Analysis of Prostate Cancer Diagnostics

Recent developments in prostate cancer diagnostics call for appropriate tools to frame the ethical assessment of diagnostic practice. The first aim is to identify ethically important features and ethical principles of key importance for prostate cancer diagnostics. Next, we need to argue which ethical theory justifies these principles and can therefore be used for ethical assessment in the field. The standard medical procedure for prostate cancer diagnostics offered by the Danish health care system is used as an example.

Prescription rates for commonly used drugs before and after a prostate cancer diagnosis

PURPOSE

To investigate differences in prescription rates of commonly used drugs among prostate cancer patients and cancer-free comparisons and between patients diagnosed with localized and non-localized disease.

METHODS

We conducted a register-based study including all men aged 50-85 years diagnosed with prostate cancer in Denmark from 1998 to 2015 and an age-matched cancer-free comparison cohort. We calculated the number of new and total prescriptions from three years before to three years after the date of diagnosis of the case for selected drug classes divided by the number of person-months and stratified by stage at diagnosis.

RESULTS

We included 54,286 prostate cancer patients and 249,645 matched comparisons. 30,712 patients were diagnosed with localized disease and 12,884 with non-localized disease. The rates of new prescriptions increased considerably among patients within the year before the diagnosis. Hereafter the rates varied between drug classes. For most drug classes, total prescription rates for patients and comparisons increased similarly in the study period. Total prescription rates varied between men with localized and non-localized disease for all drug classes apart from statins.

CONCLUSION

Our findings indicate that a large proportion of prostate cancer cases are likely diagnosed during medical work-up for other reasons than prostate cancer. Increased rates occur within the last year before diagnosis and future studies on the interaction between drug use and prostate cancer should at least include a one year pre-diagnostic lag-time. Post-diagnostic prescription rates demonstrated an increased use of drugs most likely associated with the consequences of the disease.