Are Men Making Informed Decisions According to the Prostate-Specific Antigen Test Guidelines? Analysis of the 2015 Behavioral Risk Factor Surveillance System

Shared decision-making before prostate cancer screening decisions

Decisions around prostate-specific antigen screening require a patient-centred approach, considering the benefits and risks of potential harm. Using shared decision-making (SDM) can improve men's knowledge and reduce decisional conflict. SDM is supported by evidence, but can be difficult to implement in clinical settings. An inclusive definition of SDM was used in order to determine the prevalence of SDM in prostate cancer screening decisions. Despite consensus among guidelines endorsing SDM practice, the prevalence of SDM occurring before the decision to undergo or forgo prostate-specific antigen testing varied between 11% and 98%, and was higher in studies in which SDM was self-reported by physicians than in patient-reported recollections and observed practices. The influence of trust and continuity in physician-patient relationships were identified as facilitators of SDM, whereas common barriers included limited appointment times and poor health literacy. Decision aids, which can help physicians to convey health information within a limited time frame and give patients increased autonomy over decisions, are underused and were not shown to clearly influence whether SDM occurs. Future studies should focus on methods to facilitate the use of SDM in clinical settings.

Racial Disparities in Prostate Cancer Screening: The Role of Shared Decision Making

INTRODUCTION

The 2018 U.S. Preventive Services Task Force recommendations endorsed shared decision making for men aged 55-69 years, encouraging consideration of patient race/ethnicity for prostate-specific antigen screening. This study aimed to assess whether a proxy shared decision-making variable modified the impact of race/ethnicity on the likelihood of prostate-specific antigen screening.

METHODS

A cross-sectional analysis of men aged between 55 and 69 years, who responded to the prostate-specific antigen screening portions of the 2020 U.S.-based Behavioral Risk Factor Surveillance System survey, was performed between September and December 2022. Complex sample multivariable logistic regression models with an interaction term combining race and estimated shared decision making were used to test whether shared decision making modified the impact of race/ethnicity on screening.

RESULTS

Of a weighted sample of 26.8 million men eligible for prostate-specific antigen screening, 25.7% (6.9 million) reported for prostate-specific antigen screening. In adjusted analysis, estimated shared decision making was a significant predictor of prostate-specific antigen screening (AOR=2.65, 95% CI=2.36, 2.98, p<0.001). The interaction between race/ethnicity and estimated shared decision making on the receipt of prostate-specific antigen screening was significant (pint=0.001). Among those who did not report estimated shared decision making, both non-Hispanic Black (OR=0.77, 95% CI=0.61, 0.97, p=0.026) and Hispanic (OR=0.51, 95% CI=0.39, 0.68, p<0.001) men were significantly less likely to undergo prostate-specific antigen screening than non-Hispanic White men. On the contrary, among respondents who reported estimated shared decision making, no race-based differences in prostate-specific antigen screening were found.

CONCLUSIONS

Although much disparities research focuses on race-based differences in prostate-specific antigen screening, research on strategies to mitigate these disparities is needed. Shared decision making might attenuate the impact of race/ethnic disparities on the likelihood of prostate-specific antigen screening.

Prevalence of Shared Decision-making in Prostate Cancer Screening in New York State

Current guidelines recommend that physicians use a shared decision-making (SDM) approach to engage with patients on the potential benefits and harms of prostate cancer screening based on their individual risk. In a sample of 4,118 men aged 55-69 from the 2018 New York State Behavioral Risk Factor Surveillance Survey (BRFSS), we compared the frequency of screening recommendations and SDM conversations according to four race/ethnic groups. In logistic regression, we evaluated the likelihood of SDM conversations between race/ethnic groups. Our findings suggest that the odds of never having a SDM conversation with their healthcare provider were significantly higher among Hispanic men (OR 95% CI: 2.10, 1.11-3.99) and other/multiracial men (OR, 95% CI: 3.08, 1.46-6.52) compared to white men, while black men had comparable odds (1.52, 0.98-2.34). The lower frequency of SDM conversation among Hispanic and other/multiracial men suggest a missed opportunity for healthcare providers to guide informed screening decisions.

Training Community African American and Hispanic/Latino/a Advocates on Prostate Cancer (PCa): a Multicultural and Bicoastal Approach

African American communities are disproportionately impacted by prostate cancer (PCa) compared to other racial/ethnic groups. Whereas the incidence of PCa in Hispanic/Latino men is lower than the incidence in non-Hispanic/Latino White men, Hispanic/Latino men are more likely to be diagnosed with PCa in late stages, and less likely to be knowledgeable about PCa, resulting in significant disparities. We developed, culturally adapted, translated, implemented, and evaluated a PCa Cancer Advocacy Training in African American and Hispanic/Latino/a communities. Culturally and language specific content for African American and Hispanic/Latino/a patients on PCa causes, risk factors, epidemiology, detection, diagnosis, and treatment were delivered through a workshop and simultaneously broadcasted in Spanish in Los Angeles County (n = 29) and in English in Tallahassee, FL (n = 9). Pre- and posttest surveys assessed impact. Pre vs post differences were statistically significant in knowledge (5.0 ± 1.6 vs 6.3 ± 1.1) and advocacy intentions (3.9 ± 0.9 vs 4.3 ± 0.8), on correctly identifying warning signs for PCa (50% vs 87%), intent to inform and educate about PCa within the next 3 months (69% vs 95%), to ensure that high-quality research is sensitive to the priorities of patients (63% vs 84%), to help increase patient recruitment, compliance, and retention for clinical trials within the next month (62% vs 84%), intent to engage in PCa patient education within the next 3 months (67% vs 92%), and in engaging in PCa community outreach within the next 3 months (67% vs 94%). There were no significant differences due to race/ethnicity. The Cancer Advocacy Training led to increased knowledge, awareness, and intention to engage in advocacy regarding PCa in the next 3 months. Results suggest that delivering culturally and language specific educational information increases engagement of Hispanic/Latino/a and African American patient/community advocates.

Associations of Content and Context of Communication with Prostate-Specific Antigen Testing

There is limited research about the content and context of communication on prostate-specific antigen (PSA) testing among men in the state of Florida. The purpose of this study is to understand how the content communication (discussion of advantages and disadvantages of PSA testing between provider and patient; provider recommendations of PSA testing) and the context of communication (continuity of care denoted by the presence of a personal doctor) influence PSA testing. Data were drawn from the Florida Behavioral Risk Factor Surveillance System. Receipt of PSA testing was the primary outcome. Multiple logistic regression analyses were used to adjust for sociodemographic, clinical, healthcare access, and lifestyle characteristics when associating the content and context of communication with PSA testing. Discussions were classified into four mutually exclusive categories: discussions of advantages and disadvantages, only advantages, only disadvantages, and no discussion. The most significant predictors for PSA testing included physician recommendation, discussions including advantages, older age, non-smoking, and having a personal doctor. Individualized PSA screening may be a pathway to reducing racial disparities in screening for prostate cancer (PCa) and, by extension, lower incidence and mortality rates. Developing a bill to create an Office of Men's Health at Health & Human Services is recommended.

Patient perspectives of prostate cancer screening vary by race following 2018 guideline changes

BACKGROUND

The 2018 US Preventive Services Task Force guidelines recommend individualizing prostate cancer screening in 55- to 69-year-old men. Given the higher incidence of prostate cancer in African American (AA) compared to non-Hispanic White (NHW) men, this study compared reported rates of prostate-specific antigen (PSA) screening hypothesizing that it would not be commensurate with the relative risk between these two groups.

METHODS

Using the 2020 Behavioral Risk Factor Surveillance System, we identified 43,685 men (40,301 NHW and 3384 AA) interviewed about PSA screening.

RESULTS

AA men had an odds ratio (OR) of 0.80 (95% confidence interval [CI], 0.69-0.93; p = .004) of reporting PSA screening; sequentially correcting for access to care, smoking, and age had minimal effect on this finding, but when correcting for income significantly attenuated this difference (OR, 0.95; 95% CI, 0.81-1.12). Further adding education level eliminated the effect size of AA race entirely with OR, 0.99 (95% CI, 0.84-1.17; p = .91). Further analysis found significant interaction between education and race, with college-educated AA men having 1.42 OR of receiving screening compared to college-educated NHW men.

CONCLUSIONS

Despite prostate cancer being more common and having higher population-level mortality in AA than NHW men, PSA screening and education patterns do not reflect this increased risk even when adjusting for health access disparities. The authors' findings of significant effect from both income and education suggest that systemic racism is an important factor in the observed difference in PSA screening between AA men and NHW men.

LAY SUMMARY

In the United States, prostate cancer is more common in African American men New guidelines from 2018 encourage physicians to consider risk factors in deciding whether or not to recommend screening, but overall African American men continue to be screened at a lower rate than non-Hispanic White men This effect disappears when correcting for income and education level, suggesting that several factors including systemic racism, medical mistrust, and self-advocacy may impact this observed difference.

How Much Information Do Icelandic Men Receive on Pros and Cons of Prostate-Specific Antigen Testing Prior to Undergoing Testing?

Prostate-specific antigen (PSA) testing for asymptomatic men is neither encouraged nor discouraged in most countries; however, shared decision-making is emphasized prior to PSA testing. The objective of this study was to examine to what extent Icelandic men receive information about the pros and cons of PSA testing. Furthermore, to explore if patient–provider communication about pros and cons of PSA testing has improved in the last decade during which time more emphasis has been placed on shared decision-making. All Icelandic men diagnosed with prostate cancer in the years 2015 to 2020 were invited to participate, and a total of 471 out of 1002 men participated (response rate 47.0%). Participants’ age ranged from 51 to 95 years (M = 71.9, SD = 7.3). Only half of the men received information about the pros and cons of PSA testing, a third did not receive any information prior to testing and, alarmingly, 22.2% of the men did not even know that they were being tested. A majority of the participants lacked knowledge about the testing with half of the men reporting that they had no knowledge about pros and cons of PSA testing prior to testing. The findings have major public health relevance as they indicate that information provided prior to PSA testing continue to be deficient and that there is a pressing need for interventions that educate men about the benefits and limitations of PSA testing before men undergo medical procedures that can seriously affect their quality of life.

Examination of prostate-specific antigen (PSA) screening in military and civilian men: analysis of the 2018 behavioral risk factor surveillance system

PURPOSE

To determine whether military men report different prostate-specific antigen (PSA) screening rates than civilian men and if shared decision-making (SDM) is associated with PSA screening.

METHODS

We used data from the 2018 Behavioral Risk Factor Surveillance System and included 101,901 men (26,363 military and 75,538 civilian men) in the analysis conducted in 2021. We conducted binomial logistic regression analyses to determine covariate-adjusted associations between military status and receiving a PSA test in the last 2 years. We then added patient reports of SDM to the model. Finally, we looked at the joint effects of military status and SDM on the receipt of a PSA test in the last 2 years.

RESULTS

Military men had 1.1 times the odds of PSA testing compared to civilian men (95% CI 1.1, 1.2) after adjusting for SDM and sociodemographic and health covariates. When examining the joint effect of military status and SDM, military and civilian men had over three times the odds of receiving a PSA test in the last 2 years if they had reported SDM (OR 3.5 and OR 3.4, respectively) compared to civilian men who did not experience SDM.

CONCLUSION

Military men are slightly more likely to report receiving a PSA test in the last 2 years compared to civilian men. Additionally, results show SDM plays a role in the receipt of a PSA test in both populations. These findings can serve as a foundation for tailored interventions to promote appropriate SDM for PSA screening in civilian, active duty, and veteran healthcare systems.

Does Shared Decision-Making for Prostate Cancer Screening Among African American Men Happen? It Depends on Who You Ask

BACKGROUND

Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known about how this process is perceived by patients and providers. SDM is especially important for African American men, who are at high risk for the disease.

OBJECTIVE

To evaluate agreement in SDM ratings among patients, providers, and objective observers.

METHOD

African American men ages 45-70 were recruited from primary care practices to participate in a study evaluating a decision aid (DA). Immediately after using the DA, patients proceeded to primary care appointments. Afterwards, patients and physicians completed surveys assessing perceptions about SDM. Clinical visits were also audio-recorded and coded to assess SDM.

RESULTS

Mean scores on SDM measures among patients were 73.2 (SD = 27.5, 95% CI 55.71-90.62), 83.1 among physicians (SD = 7.8 95% CI 78.14-88.06), and 67.1 among objective raters (SD = 36.8 95% CI 43.72-90.45). Among patient-provider dyads, mean agreement was 49.9%.

CONCLUSION

Patients, physicians, and objective observers perceived SDM differently. Understanding discordant experiences of SDM is vital for improving clinical guidance about SDM especially among African Americans who have historically faced healthcare discrimination and mistrust. DAs, particularly for African American men, should incorporate strategies to empower patients to advocate for their communication needs and preferences.

TRIAL REGISTRATION

Clinical trials identifier number: NCT02787434.

Nonlinear Relationship Between Age and Likelihood of Undergoing Prostate-Specific Antigen Testing, and the Predictive Factors of Testing at Different Ages

OBJECTIVE

To investigate the nonlinear relationship between age and the likelihood of undergoing prostate-specific antigen (PSA) testing, and the difference of factors influencing the test likelihood among subjects aged 40-54, 55-69, and ≥70 years.

METHODS

Data were extracted from the 2018 Behavioral Risk Factor Surveillance System, with the primary outcome defined as receipt of a PSA test within the previous 12 months. Restricted cubic splines were used to assess the relationship between age and the likelihood of undergoing PSA testing. Backward conditional logistic regression analyses were used to identify the predictors of undergoing PSA testing among subjects aged 40-54, 55-69, and ≥70 years.

RESULTS

Finally, 92,177 people were identified. The likelihood of PSA testing increased up to around 71 years old and then decreased rapidly for higher ages, showing a clear nonlinear inverted U-shaped relationship with age (p < .001). Insurance status, shared decision-making, whether a recommendation for PSA testing had been accepted, income level, smoking status, and age were the common predictors of testing in the three age groups. However, the predictors differed somewhat among the three groups: being overweight or obese was only positively associated with increased testing among people aged 40-54 and ≥70 years, being retired only greatly impacted the test likelihood among those aged 40-54 years, and the general health status, marital status, and race affected people aged ≥55 years.

CONCLUSION

The factors influencing PSA screening differ with age, which should be fully considered when screening different target age groups.

Effect of a Prostate Cancer Screening Decision Aid for African-American Men in Primary Care Settings

BACKGROUND

African-American men have an elevated risk of developing and dying from prostate cancer. Shared decision-making (SDM) about prostate cancer screening is recommended but does not always occur.

METHODS

We pilot-tested an online decision aid (DA) in primary care settings using a pre/postevaluation design among African-American men ages 45 to 70 years. Men completed surveys before and after using the DA, which had interactive segments (e.g., values clarification) and provided individualized assessment of prostate cancer risk. Primary outcomes included prostate cancer knowledge, confidence in ability to make informed decisions, decisional conflict, and satisfaction with the decision. Immediately after the clinical visit, patients reported the degree to which they were engaged by their provider in SDM.

RESULTS

Among this sample of men (n = 49), use of the DA was associated with increased knowledge about prostate cancer [mean = 55.3% vs. 71.2%; 95% confidence interval (CI), 9.8-22.1; P < 0.001], reduced decisional conflict (mean = 33.4 vs. 23.6; 95% CI, -18.1 to -1.6; P = 0.002) on a scale from 0 to 100, and a decreased preference to be screened (88% vs. 69%; 95% CI, 0.09-0.64; P = 0.01). Most (89%) reported that the DA prepared them well/very well for SDM with their provider. Following the clinical visit with providers, scores on perceived involvement in SDM were 68.1 (SD 29.1) on a 0 to 100 scale.

CONCLUSIONS

The DA improved men's knowledge, reduced decisional conflict, and promoted the perception of being prepared for SDM.

IMPACT

Findings suggest that use of an online DA to improve SDM outcomes warrants further testing in a future trial.

A discussion on controversies and ethical dilemmas in prostate cancer screening

Prostate cancer (PCa) is one of the the most common cancers in men. A blood test called prostate-specific antigen (PSA) has a potential to pick up this cancer very early and is used for screening of this disease. However, screening for prostate cancer is a matter of debate. Level 1 evidence from randomised controlled trials suggests a reduction in cancer-specific mortality from PCa screening. However, there could be an associated impact on quality of life due to a high proportion of overdiagnosis and overtreatment as part of the screening. The US Preventive Services Task Force (USPSTF) in 2012 recommended that PSA-based PCa screening should not to be offered at any age. However, considering the current evidence, USPSTF recently revised its recommendation to offer the PSA test to men aged 55-69 years with shared decision-making, in line with earlier guidelines from the American Cancer Society and the American Urological Association. A shared decision making is necessary since the PSA test could potentially harm an individual. However, the literature suggests that clinicians often neglect a discussion on this issue before ordering the test. This narrative discusses the main controversies regarding PCa screening including the PSA threshold for biopsy, the concept of overdiagnosis and overtreatment, the practical difficulties of active surveillance, the current level 1 evidence on the mortality benefit of screening, and the associated pitfalls. It offers a detailed discussion on the ethics involved in the PSA test and highlights the barriers to shared decision-making and possible solutions.