Primary Care Physicians Beliefs about Prostate-Specific Antigen Evidence Uncertainty, Screening Efficacy, and Test Use.

BACKGROUND/PURPOSE: Little is known about primary care physicians' (PCPs) beliefs about prostate cancer screening efficacy, evidence uncertainty, and their actual screening behaviors. We examined factors associated with PCP beliefs about screening efficacy and uncertainty and whether beliefs were associated with prostate specific-antigen (PSA) test use. METHODS: The 2008 National Survey of Primary Care Physicians' Practices Regarding Prostate Cancer Screening collected information on physicians' attitudes, beliefs, and practices related to prostate cancer and screening (n=1,256). Two factors were constructed that measured belief in certainty of evidence for PSA testing and belief in screening efficacy. These factors, along with PCP sociodemographic and practice-related factors, were used to examine associations with offering the PSA test. RESULTS: Most PCPs were male (70%), Caucasian (76%), under age 50 (56%), and practiced in communities with more than 50,000 residents (54%). In bivariate analysis, variables associated with PCP belief in evidence uncertainty included female gender, younger age, and lower patient volume. Variables associated with belief in screening efficacy included older age and general and family practice specialty. After adjustment, PCPs with high belief in evidence uncertainty were less likely (OR=0.19, 95% CI=0.06, 0.62) to offer PSA and more likely to practice shared decision making (OR=1.80, 95% CI=1.22-2.67). PCPs with high belief in screening efficacy were more likely (OR=2.99, 95% CI=1.15, 7.77) to offer PSA and less likely to practice shared decision making (OR=0.47, 95% CI=0.32-0.70). CONCLUSION: Our data indicate that belief patterns about evidence uncertainty and the efficacy of using PSA may play a role in whether PCPs offer PSA.

Racial Disparity in Time Between First Diagnosis and Initial Treatment of Prostate Cancer.

BACKGROUND: Disparities among patients with prostate cancer exist across the continuum of care. The interval of time that lapses between first diagnosis and treatment is another disparity that may exist but has not been fully explored. METHODS: Our study looked at the data of 749 men (353 black and 396 white) who were 40 to 81 years of age when they entered the North Carolina Central Cancer Registry during the years 2007 and 2008. Our dependent variable was the amount of months that had passed between first diagnosis and treatment. Our main independent variable was self-reported race. Covariates included age, income, level of education, insurance status, treatment received, Gleason score, and level of medical mistrust. We used negative binomial regression analysis to determine the association between the amount of time that lapsed between a diagnosis of prostate cancer and treatment by race. RESULTS: Compared with white men, black men were more likely to experience a longer wait time between diagnosis and treatment of prostate cancer (incidence rate ratio [IRR] 1.19; 95% confidence interval [CI], 1.04-1.36). Controls for demographical, clinical, and psychosocial variables (IRR 1.24; 95% CI, 1.04-1.43) did not explain this difference between the races. CONCLUSIONS: These results suggest that the amount of time that lapses between first diagnosis and treatment of prostate cancer is longer for black men compared with white men. Our findings have identified an underreported racial disparity in the disease continuum of prostate cancer.

Factors Associated with Men's Assessment of Prostate Cancer Treatment Choice.

The objective of this study is to examine factors among a group of African American and White men in North Carolina and their assessment of prostate cancer treatment choice or belief that treatment chosen was best. A sample of men (N = 877) with a history of prostate cancer diagnosis was recruited from the North Carolina Cancer Registry during 2007-2008 and asked to participate in a telephone interview covering several measures about their initial prostate cancer treatment. Logistic regression was used to assess demographic, psychosocial, and clinical factors on whether they felt that they had chosen the best treatment for the disease. Respondents were majority White (52.7 %), married (75.9 %), and had surgery (67.9 %) as their initial treatment. At the bivariate level, factors associated with the belief that the treatment chosen was best were as follows: White race/ethnicity, higher levels of education, a more recent treatment date, having health insurance coverage, type of treatment received, higher levels of bother from side effects, greater contentment with their quality of life, and doctor discussions of the various treatment options. Similarly, the multivariate analysis showed increased odds of belief that the treatment chosen was the best among demographic (i.e., race/ethnicity, level of education, and health insurance coverage) as well as psychosocial and clinical variables (i.e., greater bother from side effects, greater contentment with their quality of life, and initial treatment received). Results suggest that demographic, psychosocial, and clinical factors play an important role for men in assessing their treatment choices for prostate cancer.

Complementary and alternative medicine (CAM) use among men with a history of prostate cancer.

Complementary and alternative medicine (CAM) has been commonly used among Americans; however, less is known about its use among men with a history of prostate cancer. This study used the 2002 National Health Interview Survey (NHIS) to explore the amount and type of CAM use among 218 Black and White men with a history of prostate cancer. Over 90% of men reported having ever used any form of CAM and most men used biologically-based and mind-body therapies. Nurses are in a unique position to discuss, to assess needs and practices, and perhaps, to act as intermediaries for physicians and other healthcare professionals and prostate cancer survivors who use CAM.

Discussions about prostate cancer screening between U.S. primary care physicians and their patients.

OBJECTIVE: This study examined the likelihood that U.S. primary care physicians (PCPs) discuss and recommend prostate cancer screening with their patients and physician-related and practice-related factors associated with this behavior. METHODS: We analyzed data from the 2007-2008 National Survey of Primary Care Physician Practices Regarding Prostate Cancer Screening (N = 1,256), the most recent and comprehensive survey specifically designed to address issues concerning prostate cancer screening and representing nearly 95,000 PCPs. We evaluated the relationship between PCP behavior regarding prostate cancer screening discussions and covariates, including PCP demographic and practice-related factors. Weighted percentages and Chi-square tests were used to compare use of screening discussions by PCP characteristics. Adjusted odds of discussing screening and recommending the PSA test were determined from logistic regression. RESULTS: Eighty percent of PCPs reported that they routinely discuss prostate cancer screening with all of their male patients, and 64.1% of PCPs who discussed screening with any patients reported that they attempted to talk their patients into getting the PSA test. In multivariate analyses, encouraging PSA testing was more likely among non-Hispanic black PCPs (OR = 2.80, 95% CI [1.88, 4.16]), PCPs serving 100 or more patients per week (OR = 2.16, 95% CI [1.38, 3.37]), and PCPs spending longer hours per week in direct patient care (31-40 hours: OR = 1.90, 95% CI [1.13, 3.20]; 41 or more hours: OR = 2.09, 95% CI [1.12, 3.88]), compared to their referents. PCPs in multi-specialty group practice were more likely to remain neutral or discourage PSA testing compared to PCPs in solo practice. CONCLUSIONS: Both individual and practice-related factors of PCPs were associated with the use of prostate cancer screening discussions by U.S. PCPs. Results from this study may prove valuable to researchers and clinicians and help guide the development and implementation of future prostate cancer screening interventions in the U.S.

Trends in prostate-specific antigen test use, 2000-2005.

OBJECTIVE: This study examined prostate-specific antigen (PSA) test use among men and identified sociodemographic and health-related characteristics associated with its use over time. METHODS: The National Health Interview Survey collected information on PSA test use among 16,058 men > or = 40 years of age in 2000 and 2005. We examined two outcomes: (1) having had a recent (within two years) screening PSA test and (2) having had three or more PSA tests in the past five years (to indicate frequent use). RESULTS: Marital status, family history of prostate cancer, and having seen a doctor in the past year differed over time in the unadjusted model. In the adjusted model, recent PSA screening decreased from 2000 to 2005 for single, never-married men, but increased for men with chronic diseases. Frequent PSA test use increased for men with a family history of prostate cancer, men with chronic diseases, and men who had seen a physician in the past year. Significant correlates of higher recent PSA test use included being older, married, and of black race/ethnicity; having higher levels of education and income, health-care coverage, and a usual place of health care; and increased comorbidity. CONCLUSION: Major organizations are not in agreement about the efficacy of prostate cancer screening; however, men > or = 40 years of age continue to use the PSA test. Both recent screening and frequent testing showed variability during the study period and may have implications for the ongoing randomized clinical trials that are expected to clarify whether early detection of prostate cancer with PSA testing increases survival.

Racial differences in PSA screening interval and stage at diagnosis.

OBJECTIVES: This study examined PSA screening interval of black and white men aged 65 or older and its association with prostate cancer stage at diagnosis. METHODS: SEER-Medicare data were examined for 18,067 black and white men diagnosed with prostate cancer between 1994 and 2002. Logistic regression was used to assess the association between race, PSA screening interval, and stage at diagnosis. Analysis also controlled for age, marital status, comorbidity, diagnosis year, geographic region, income, and receipt of surgery. RESULTS: Compared to whites, blacks diagnosed with prostate cancer were more likely to have had a longer PSA screening interval prior to diagnosis, including a greater likelihood of no pre-diagnosis use of PSA screening. Controlling for PSA screening interval was associated with a reduction in blacks' relative odds of being diagnosed with advanced (stage III or IV) prostate cancer, to a point that the stage at diagnosis was not statistically different from that of whites (OR=1.12, 95% CI=0.98-1.29). Longer intra-PSA intervals were systematically associated with greater odds of diagnosis with advanced disease. CONCLUSIONS: More frequent or systematic PSA screening may be a pathway to reducing racial differences in prostate cancer stage at diagnosis, and, by extension, mortality.

Patterns in prostate-specific antigen test use and digital rectal examinations in the Behavioral Risk Factor Surveillance System, 2002-2006.

BACKGROUND: Studies have examined prostate-specific antigen (PSA) test and digital rectal examination (DRE) use among men; however, few have examined use of these procedures together over time. This study examined use of the PSA test and DRE among men over time and identified correlates associated with test use for the PSA test only, the DRE only, and both procedures combined. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS) collected information on prostate cancer test use among 229,574 men aged 40 or older over 3 years (2002, 2004, and 2006). Patterns of PSA test and DRE use were examined overall and by selected demographic and health-related characteristics. Correlates of recent PSA test and DRE use were determined using logistic regression. RESULTS: Overall trends for years 2002-2006 were a significant increase for PSA use only and a significant decrease of PSA and DRE use combined. Having had a recent PSA test (within 2 years) only; a recent DRE only; or both tests varied by sociodemographic and health-related variables, including age, race/ethnicity, marital status, levels of education and income, body mass index, health insurance status, and having a personal doctor or health care provider. CONCLUSION: Although major organizations are not in agreement about the efficacy of prostate cancer screening, the PSA test and DRE continue to be utilized regularly by a majority of American men over age 40. PSA test and DRE use in this population provide a basis for addressing issues related to screening.

Prostate-specific antigen test use and digital rectal examinations among African-American men, 2002-2006.

African-American men experience greater incidence and mortality from prostate cancer compared to White men as well as men from other groups. Few studies have examined prostate-specific antigen (PSA) test and digital rectal examination (DRE) use in African-American men. This study examined use of the PSA test and DRE among African-American men over time and identified correlates associated with the use of these procedures. Overall trends for years 2002-2006 showed a significant decrease in recent PSA test use and DRE among African-American men in 2004 and 2006 compared to year 2002. Recent PSA test use and DRE were associated with several factors including older ages, being married, higher levels of education and income, and overweight and obese body mass index (BMI). PSA test use and DRE among African-American men should be monitored over time to find out if this pattern continues.

Use of the prostate-specific antigen test among U.S. men: findings from the 2005 National Health Interview Survey.

BACKGROUND: Although evidence that prostate cancer deaths are reduced by screening for elevated prostate-specific antigen (PSA) concentration coupled with early diagnosis and treatment is insufficient to advocate routine screening for prostate cancer, PSA testing has become more common in the past decade. We examined characteristics that might influence testing and compared test use between men ages 40 to 49 and 50 to 79 years. METHODS: We used data from 7,669 participants with no history of prostate cancer in the 2005 National Health Interview Survey. RESULTS: Among men reporting about PSA testing, an estimated 16% of 40- to 49-year-old men and 49% of 50- to 79-year-old men had a PSA test in the past 2 years. In multivariate analyses, among men ages 40 to 49 years, non-Hispanic Black men were more likely (P < 0.05) to have had a PSA test than non-Hispanic White men. We found no significant difference by race/ethnicity in men ages 50 to 79 years. Higher education, higher poverty threshold, usual source of medical care, family history of prostate cancer, and comorbid conditions were associated with increased PSA test use in both age groups. Additionally, men ages 50 to 79 years born in the United States, who were married, had private or military health insurance, and had been diagnosed with another cancer type were more likely to be tested. CONCLUSIONS: Findings from the multivariate analyses indicated significantly higher PSA test use among younger non-Hispanic Black men than among non-Hispanic White men. These findings may indicate that healthcare providers are getting and conveying the message of increased risk of prostate cancer among African American men.

Differences in lower urinary tract symptoms, treatment and mortality among African-American and white elderly men.

BACKGROUND: There are limited population-based studies of benign prostate hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in men, and most studies examined to date have been restricted to predominately white populations. This study examines treatment and all-cause mortality among a cohort of African-American and white men aged > or =65 with BPH/LUTS symptoms over time. METHODS: Data were collected from the Piedmont Health Survey of the Elderly-Established Populations for the Epidemiological Study of the Elderly for 5 North Carolina counties from 1994 (N=502) to 1998 (N=322). RESULTS: From 1994-1998, there were no significant racial differences in treatment by catheter insertion, prostate surgery or drug therapy for BPH/LUTS. However, overall use of the 3 treatments increased from 1994-1998, with drug therapy showing the largest increase. Adjusted analyses revealed racial differences in prostate surgery only, with African-American men nearly 40% more likely to receive prostate surgery than white men. Men with comorbid conditions were less likely to receive drug therapy, whereas those with poor self-reported health or cancer were more likely to receive prostate surgery. Catheter insertion was more likely for those who had resided in a nursing home. Men who received drug therapy treatment or had regular rectal exams showed decreased risk of mortality. CONCLUSION: Findings suggest that healthcare providers should direct more attention to the management of LUTS in white and African-American elderly men. Data also demon-strate the need for studies that focus on treatment modalities as well as important correlates of LUTS.

Age, race, and repeated prostate-specific antigen (PSA) test use in the National Health Interview Survey.

BACKGROUND: Prostate cancer is the second leading cause of cancer death in American men. Prostate-specific antigen (PSA) test use was examined in US men aged > or = 40 years to clarify the relationship with age and race. METHODS: The National Health Interview Survey (2000) collected information about PSA test use in a representative sample of the US population. This study examined whether men reported having had three or more PSA tests within the past five years by age and race subgroups. RESULTS: Prostate-specific antigen (PSA) test use rates were lowest in men aged 40-49 and highest in men aged 65-79. Receipt of three or more PSA tests within the past five years varied by age and race. Use was higher for African-American men, compared with White men aged 40-49; similar for African-American and White men aged 50-64; higher for White than African-American men aged 65-79; and similar for African-American and White men aged > or = 80. CONCLUSION: The PSA test use patterns showed variation by age and race subgroups, and these patterns are better understood when examining both variables at the same time.

The effect of physician-patient discussions on the likelihood of prostate-specific antigen testing.

Many medical and professional organizations agree that men should discuss the advantages and disadvantages of testing for prostate-specific antigen (PSA) with their physicians before undergoing testing. In the 2000 National Health Interview Survey, men who had undergone a PSA test in the past were asked about their use of this test and discussions they had with physicians regarding its advantages and disadvantages. Among a group of 2,188 black and white men aged 40-79 years with no history of prostate cancer and a history of testing for PSA, we examined whether physician-patient discussions mediated the relationship between race and PSA testing. We specified that the test had to be their most recent one and part of a routine physical examination or screening test. We compared those tested within the past two years with those tested >2 years. Almost two-thirds of the men previously had discussions with their physicians about the advantages and disadvantages of the PSA test. Older men, college graduates, those living in the midwest and those with health insurance were more likely to have been tested recently. Discussion with a physician was found to mediate the relationship between race and PSA testing during the past two years. Black men were initially found to be more likely than white men to have been screened recently [odds ratio (OR)=1.45; 95% confidence interval (CI) 1.01-2.07], but in the full model race was no longer significant (OR=1.41; 95% Cl 0.98-2.03). Discussions about PSA testing were associated with more recent PSA screening (OR=1.38, 95% CI 1.05-1.82). These findings suggest that: 1) the relationships among race, physician discussions and PSA testing may need to be examined in more complex ways, and 2) the physician has an important role in men's decision to consider PSA testing.

Formative evaluation of the prostate cancer screening practices of African-American physicians.

BACKGROUND: Clinical guidelines for using the prostate-specific antigen (PSA) test as a population-based tool vary. This study qualitatively explores the prostate cancer screening practices of African-American primary care physicians. METHODS: Eight telephone focus groups were conducted with 41 African-American primary care physicians from 22 states. Data were coded on five major topic areas relative to provider screening practices: use of serum PSA and digital rectal examination (DRE), counseling routine, factors influencing screening practices, familiarity with clinical guidelines, and use of educational materials RESULTS: Almost all (95%) of the physicians routinely recommended and offered prostate cancer screening to their patients, which was universally defined as consisting of both a PSA test and DRE. Most physicians reported offering the PSA test to asymptomatic, non-African-American men beginning around age 50, but African-American men or men with a family history of prostate cancer were offered the PSA test 5-10 years earlier. CONCLUSIONS: The observed practice patterns for prostate cancer screening among African-American primary care physicians do not evenly reflect both sides of the PSA screening controversy. For most physicians, concerns about prostate cancer in their patients outweighed concerns about the potential limitations of screening and the untoward side effects of treatment. These physicians adopted a more proactive approach toward use of the PSA test in asymptomatic men irrespective of their race or ethnicity.

Using telephone focus groups methodology to examine the prostate cancer screening practices of African-American primary care physicians.

African-American men have a greater burden from prostate cancer than do white men and men of other races/ethnicities in the United States. To date, there have been no studies of how African-American primary care physicians screen their patients for prostate cancer. The purpose of this study was to examine the use of telephone focus groups as a methodology and to learn about this practice among a group of African-American primary care physicians. A total of 41 physicians participated in eight telephone focus groups. Results from the study are found in a separate article. Regarding telephone focus group methodology, we found that a majority of the physicians in this study preferred telephone focus groups over the conventional face-to-face focus groups. We also discuss some of the advantages (e.g., no travel, high acceptance rates, more flexibility than in-person groups, and general cost efficiency) as well as disadvantages (e.g., nonverbal communication limits and reduction of group interaction) of this methodology. This methodology may prove useful in studies involving African-American physicians, physicians in general and other difficult-to-reach healthcare professionals.

Awareness and use of the prostate-specific antigen test among African-American men.

Although African-American men have a greater burden of prostate cancer than whites and other racial and ethnic groups, few studies on the burden of prostate cancer have focused on African Americans specifically. We used a sample of African-American men (N = 736) who participated in the 2000 National Health Interview Survey to explore their awareness of the prostate-specific antigen (PSA) test. Among African-American men aged > or = 45 with no history of prostate cancer, 63% had heard of the PSA test and 48% had been tested. Bivariate analyses showed significant associations between sociodemographic, family composition, health status and perceived risk with having heard of the PSA test and having been tested. The multivariate model showed significant associations between having heard of the PSA test and age, level of education, living in an MSA, and having private or military health insurance. For ever being tested, the multivariate model showed significant associations for age, private or military health insurance, being in fair or poor health, and having a family history of prostate cancer. Some of the correlates, such as age, increased levels of education and being married, were consistent with previous studies, but other correlates, such as metropolitan statistical area, health status and perceived risk, differed from previous studies.

African American men, prostate cancer screening and informed decision making.

Prostate cancer is the second leading cause of cancer deaths in African American men. African Americans are at increased risk over other groups and have higher mortality. Since prostate cancer is highly variable among men, medical organizations are not in agreement whether men should be screened or the appropriate ages to screen. Many of these organizations recommend discussion with patients about the benefits and limitations of screening. Some of these groups support informed decision-making (IDM). Through IDM, the patient obtains all of the information about prostate cancer including risk, to make an informed choice regarding screening. Due to several factors including lowered engagement of African American men in the healthcare system, disparities in treatment, increased risk in developing and dying from the disease, as well as other cultural and structural constraints, IDM is examined and proposed as an appropriate tool for African American men. The use of IDM is discussed, along with several challenges and cautions. We conclude with recommendations and suggestions to the provider and patient to facilitate discussions regarding prostate cancer.

African american primary care physicians' prostate cancer screening practices.

INTRODUCTION: Prostate cancer is the most common cancer and the second leading cause of cancer death among men in the United States. African American (AA) men have greater prostate cancer burden than other men. Little is known about AA primary care physicians' (PCPs) practices regarding prostate cancer screening. METHODS: We analyzed data from the 2007-2008 National Survey of Primary Care Physicians' Practices Regarding Prostate Cancer Screening. The current study included 604 AA PCPs. Outcomes assessed were (a) offering screening using the prostate-specific antigen (PSA) test, (b) use of screening discussions to involve patients in the decision to screen, and (c) having a discussion policy to try to talk the patient into getting the screening tests. RESULTS: Most AA PCPs were male (52%), younger than 50 years (61%), and had 21% to 100% AA patients in their practices (74%). The majority (94%) of AA PCPs offered prostate cancer screening using PSA, discussed the tests with their male patients to involve them in the decision to screen (83%), and had a policy to try to talk the patient into getting the screening tests (77%). Multivariate analysis showed that offering screening, use of discussions, and a usual policy to encourage taking the screening tests varied mainly by practice-related factors, including practice type, practice location, and percentage of AA patients in the practice. CONCLUSION: Data from this study indicate that most AA PCPs reported high proscreening behaviors for all 3 outcomes. Additionally, practice- and screening-related factors may be important when examining AA PCP screening behaviors.

US Primary Care Physicians' Prostate Cancer Screening Practices: A Vignette-Based Analysis of Screening Men at High Risk.

BACKGROUND: Limited information exists on primary care physicians' (PCPs) use of the prostate-specific antigen (PSA) test by patient risk category. We describe PCP responses to hypothetical patient scenario (PS) involving PSA testing among high-risk asymptomatic men. METHODS: Data were from the 2007 to 2008 National Survey of Primary Care Physicians' Practices Regarding Prostate Cancer Screening. PS#1: healthy 55-year-old white male with no family history of prostate cancer; PS#2: healthy 45-year-old African American male with no family history of prostate cancer; and PS#3: healthy 50-year-old male with a family history of prostate cancer. Data were analyzed in SAS/SUDAAN. RESULTS: Most PCPs indicated that they generally discuss the possible benefits/risks of PSA testing with the patient and then recommend the test (PS#1-PS#3 range, 53.4%-68.7%; P < .001); only about 1% reported discussing and then recommending against the test. For PS#3, compared to PS#1 and #2, PCPs were more likely to discuss and recommend the test or attempt to persuade the patient who initially declines the test. For PS#3, all clinicians generally would order/discuss the PSA test and not rely on the patient to ask. CONCLUSION: Clinicians treat family history as an important reason to recommend, persuade, and initiate PSA testing.

Prostate cancer screening practices of African-American and non-African-American US primary care physicians: a cross-sectional survey.

PURPOSE: We explored whether African-American (AA) primary care physicians (PCPs) have different prostate cancer screening practices compared to non-AA PCPs, after adjustment for potential confounding factors such as the proportion of AA patients in PCP practices. METHODS: We used SAS/SUDAAN to compare weighted responses from AA PCPs (n = 604) with those from non-AA PCPs (n = 647) in the 2007-2008 National Survey of Primary Care Physician Practices Regarding Prostate Cancer Screening. We used multivariate logistic regression to calculate the weighted odds ratios (OR) and 95% confidence intervals (CI). RESULTS: We found that AA PCPs had higher odds of working in practices with above-the-median (≥ 21%) proportions of AA male patients (OR, 9.02; 95% CI: 5.85-13.91). A higher proportion of AA PCPs (53.5%; 95% CI: 49.5-57.4) reported an above-the-median proportion (≥ 91%) of PSA testing during health maintenance exams as compared to non-AA PCPs (39.4%; 95% CI: 35.5-43.4; P < 0.0002). After adjusting for the proportion of AA patients and other factors, we found that AA PCPs had higher odds of using PSA tests to screen men (OR, 1.74; 95% CI: 1.11-2.73). CONCLUSION: This study quantifies the magnitude of the differences reported in previous focus group studies. Our results may be helpful in hypothesis generation and in planning future research studies.