Factors associated with men's use of prostate-specific antigen screening: evidence from Health Information National Trends Survey

Abstract

Background.

Rapid uptake of prostate-specific antigen (PSA) testing has occurred in the United States despite inconclusive evidence regarding mortality benefit.

Methods.

We examined data (n = 927) from the 2003 Health Information National Trends Survey to assess prevalence of self-reported PSA use and its association with patients' decision making.

Results.

Over half (55.2%) the sample reported ever having had a PSA test. Men aged 65–74 (OR = 2.53, 1.49–4.31), with some college (OR = 2.41, 1.22–4.77) or college degrees (OR = 5.01, 2.53–9.90) were more likely to have had PSA tests, while men without health insurance (OR = 0.32, 0.12–0.88) or a usual source of care (OR = 0.35, 0.22–0.54) were less likely. In a model including healthcare provider communication and information seeking, men who reported that providers involved them in decisions (OR = 1.76, 1.02–3.03) and recommended PSA (OR = 236.3, 70.5–791.4) were more likely to have had the tests. Men aged 65–74 (OR = 2.30, 1.33–4.00), with college degrees (OR = 2.91, 1.45–5.82), and greater information attention/seeking (OR = 1.23, 1.07–1.40) were more likely to report PSA recommendations, while those without usual care were less likely (OR = 0.37, 0.22–0.64). Men without usual care (OR = 0.38, 0.20–0.71) and Hispanic men (OR = 0.40, 0.19–0.85) were less likely to report that healthcare providers involved them in healthcare decisions.

Conclusions.

Results emphasize the relevance of patient decision making and the importance of healthcare providers in PSA testing.

Introduction

Prostate cancer poses a significant public health problem in the United States as the most common non-skin cancer diagnosis and the second leading cause of cancer mortality among American men [1]. Interest in prostate cancer testing has increased since the early 1990s, with rapid uptake of prostate-specific antigen (PSA) testing for prostate cancer. Data from the 2000 National Health Interview Survey show that 41% of U.S. men aged 50 and older reported having had a PSA test within the last year [2]. PSA rates are similar to rates for colorectal cancer screening (home stool blood test within the past year or colorectal endoscopy within the past 5 years), for which a mortality benefit has been demonstrated [2]. Furthermore, given that some men may have PSA tests done without their active consent (e.g., as part of blood chemistry), self-reports of PSA use may underestimate actual testing prevalence [3], [4], [5].

Although PSA testing may play some role in recent declines in prostate cancer mortality, the data are not conclusive [1]. The U.S. Preventive Services Task Force recently reviewed the evidence on the relationship between PSA testing and prostate cancer mortality and concluded that there is insufficient evidence to support recommendations for routine screening of the general population [6], [7], [8]. Mortality data from ongoing randomized controlled trials, the U.S. National Cancer Institute's Prostate, Lung, Colorectal and Ovarian Cancer Screening (PLCO) Trial, and the European Randomized Study of Screening for Prostate Cancer, will not be available for several years. Furthermore, it is not clear whether the benefits of screening outweigh potential risks [6], [9], [10], [11], [12]. Positive PSA tests require additional testing that may lead to more invasive diagnostic procedures. Radical prostatectomy and radiation treatments for prostate cancer may also produce complications such as erectile dysfunction and urinary incontinence [13]. Given the lack of definitive evidence of a mortality benefit for PSA screening, most professional organizations do not recommend routine PSA screening for all age-eligible men [14]. Rather, most organizations recommend that healthcare providers discuss testing and arrive at informed decisions with their male patients over age 50 [6], [15], [16], [17].

Sociodemographic characteristics, such as age, race/ethnicity, education, and income, have been associated with PSA use in previous research [2], [18], [19], [20], [21], [22]. The prevalence of PSA use increases with age [2], [18], [20], [21], education, and income [2], [19]. Lower utilization rates have been documented among Hispanics, non-Hispanic Asians, and recent immigrants to the United States [2]. Not surprisingly, higher rates of PSA use are found among men with health insurance and a usual source of healthcare [2], [19], [20], [21]. Provider recommendations for PSA testing also are associated with higher utilization rates [22].

The widespread use of PSA testing, coupled with controversies about PSA screening, have raised awareness about the need for men to understand the benefits and limitations of PSA tests. Thus, it is appropriate to examine patient decision making with regard to PSA test use [23]. Two complementary healthcare decision making models that have been proposed are shared decision making (SDM) and informed decision making (IDM). SDM occurs in clinical settings and is characterized by active provider involvement, mutual information sharing between the patient and provider, and expressions of patient preferences [24]. IDM occurs when patients understand their disease or condition and the particular test, regimen, or treatment under consideration. SDM and IDM are mutually supportive decision making processes wherein the patient (1) understands the risks and seriousness of a given health matter, (2) understands the risks, benefits, uncertainties, and alternatives to available preventive services, (3) has considered his or her values and preferences regarding the preventive service, and (4) has participated in decision making about the service at a desired and comfortable level [23], [24]. While SDM is limited to clinical settings, IDM may be cultivated both within and outside of the clinical setting. Moreover, IDM on the part of participants is required for SDM; thus, patients must be informed to share in the decision making process.

SDM and IDM are particularly relevant to PSA test use because many professional organizations recommend that healthcare providers tailor decisions about PSA testing to individual patients by discussing the risks and benefits of the test and by taking patients' risks, values, and preferences into account [6], [15], [16], [17]. Within the SDM paradigm, men's decisions about PSA testing are likely to be influenced by communication with healthcare providers including whether healthcare providers recommend PSA. IDM is not limited to the clinical setting, and does not require real-time communication between patients and heath care providers. However, if patients do not get the information from healthcare providers, IDM requires commitment beyond the physician's office to help men understand what the PSA test is, as well as its potential benefits and limitations. The attention men pay to health information and health information seeking behavior is likely to influence the decision making process regarding PSA testing.

The purpose of this report is to (1) examine PSA test use among subgroups defined by key demographic characteristics and (2) explore the association of PSA use with factors relevant to SDM and IDM. These include respondents' perceptions of healthcare providers' communication style and attention to health information and cancer information-seeking behavior.