American Journal of Men's Health

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1 American Journal of Men's Health Physician-Patient Discussions With African American Men About Prostate Cancer Screening Louie E. Ross, Barbara D. Powe, Yhenneko J. Taylor and Daniel L. Howard American Journal of Men's Health 2008; 2; 156 originally published online Dec 5, 2007; DOI: / The online version of this article can be found at: Published by: Additional services and information for American Journal of Men's Health can be found at: Alerts: Subscriptions: Reprints: Permissions: Citations (this article cites 20 articles hosted on the SAGE Journals Online and HighWire Press platforms):

2 Physician-Patient Discussions With African American Men About Prostate Cancer Screening American Journal of Men s Health Volume 2 Number 2 June Sage Publications / hosted at Louie E. Ross, PhD, Barbara D. Powe, PhD, Yhenneko J. Taylor, MS, and Daniel L. Howard, PhD Prostate cancer is the second leading cancer killer in men. Men in general and African American men in particular face crucial decisions regarding prostate cancer screening and perhaps treatment for this disease. Major health organizations agree that men should discuss prostate cancer screening with their physicians or other health care professionals. The purpose of the study was to examine sociodemographic and other correlates of physician-patient discussions regarding the advantages and disadvantages of the prostate-specific antigen (PSA) test among African American men aged 40 or older. A majority of African American men reported having discussed the advantages and disadvantages of prostate cancer screening and/or testing with their physicians before ordering it, and physician-patient discussions about the PSA test were associated with increased screening in African American men. Inasmuch as African American men have greater prostate cancer incidence and mortality over other groups, future attempts should be made to find meaningful correlates of PSA screening and test use to help reduce the burden of this disease. Keywords: prostate cancer screening; PSA test; physician-patient discussions Prostate cancer continues to rank highest in incidence and second highest in mortality among older men. Among its main risk factors are age (50 or older), race (African American), and family history (National Cancer Institute, 2005). Older men in general and African American men specifically have increased burden from the disease. African American men suffer a tremendous health disparity with prostate cancer, with about 60 % higher incidence and 2.4 times the mortality compared to White men (American Cancer Society, 2007). Many scientists, clinicians, agencies, and medical professional organizations are not in agreement whether men should be tested routinely for this disease. The American Cancer Society and the American From The Institute for Health, Social, and Community Research, Shaw University, Raleigh, NC (LER, YJT, DLH), and the Behavioral Research Center, American Cancer Society, Atlanta, GA (BDP). Address correspondence to: Louie E. Ross, PhD, 900 S. Wilmington St., Suite 24, Raleigh, NC 27601; lross@shawu.edu. Urological Association recommend that all men should be offered prostate-specific antigen (PSA) testing beginning at age 50 and earlier (e.g., at age 45) for men who are at high risk, that is, African American men and men with a family history of prostate cancer (American Cancer Society, 2007; American Urological Association, 2000). Other organizations, including the United States Preventive Services Task Force, the American College of Physicians, the American Academy of Family Physicians, and the American College of Preventive Medicine, suggest that evidence is insufficient to support prostate cancer screening (National Guideline Clearinghouse, 2005). Many of these organizations encourage some form of informed decision making (IDM) or shared decision making (SDM) (National Guideline Clearinghouse, 2005). Interest in IDM and SDM for cancer screening grew in the middle 1990s (Rimer, Briss, Zeller, Chan, & Woolf, 2004). IDM and SDM allow the patient to make an individual decision or a shared decision with his or her physician or give authority to make the decision to the physician or another individual (Rimer et al., 2004). 156

3 Physician-Patient Discussions With African American Men About Prostate Cancer Screening / Ross et al. 157 However, most men aged 50 or older have had at least one PSA test (Cooper, Merritt, Ross, John, & Jorgensen, 2004; Finney Rutten, Meissner, Breen, Vernon, & Rimer, 2005; Ross, Breen, Uhler, Potosky, & Blackman, 2004). What most of these organizations suggest and have in common is that physicians or other health care professionals should discuss with all men the benefits and limitations of PSA testing before offering the test (National Guideline Clearinghouse, 2005). Researchers (Dunn, Shridharani, Lou, Bernstein, & Horowitz, 2001; McFall, 2006) have examined physician discussions about prostate cancer testing with their patients. However, less research (Stat bite, 2003; Tannor & Ross, 2006) has addressed physicianpatient discussions regarding PSA testing with African American male patients, a group that has one of the highest prostate cancer incidence rates of all ethnic and racial groups. Physician-patient discussions about PSA testing have been associated with several variables such as African American race, a usual source of care, and physician initiation (McFall, 2006; Ross, Richardson, & Berkowitz, 2006). However, these physician-patient discussions regarding PSA testing related studies have reported a general lack of knowledge about prostate cancer and the advantages and disadvantages of PSA screening and a specific lack of knowledge among African American men (Agho & Lewis, 2001; Blocker et al., 2006; Chan et al., 2003; Demark-Wahnefried et al., 1995; Tannor & Ross, 2006). More recently, African American men reported physician-patient discussions about the PSA test at a higher rate than White men (McFall, 2006; Ross et al., 2006). Physician-patient discussions have also been reported to be associated with increased PSA testing among African American men (Tannor & Ross, 2006). The purpose of the current article is to examine the prevalence of African American men who reported discussing the advantages and disadvantages of the PSA screening test and to examine sociodemographic and other correlates of these discussions. Specifically, a goal of the study was to explore which set of factors among African American men are associated with having discussions with their physicians about the advantages and disadvantages of the PSA screening test. Methods The National Health Interview Survey (NHIS) is conducted annually by the National Center for Health Statistics, Centers for Disease Control and Prevention (National Center for Health Statistics, 2002). The NHIS administers face-to-face interviews in a nationally representative sample of households. Information is obtained about the health and other characteristics of each member of the household. In addition to the core questions, the NHIS (National Center for Health Statistics, 2002) collected information on cancer testing and screening during African American and Hispanic households were oversampled to obtain more precise individual estimates to examine independently as well as to permit comparisons among the various racial and ethnic groups in the survey. The current study is a secondary analysis of the NHIS 2000 survey data. Study Population The current study examined all African American men aged 40 and older who had undergone a PSA test in the NHIS African Americans composed about 10% of the sample in the NHIS However, there were only 1,692 African American men (of all ages) interviewed in this group. Inclusion criteria for the study were being male, 40 years of age or older with no diagnosis of prostate cancer, having had at least one PSA test, and the reason for the test had to be related to a routine examination or screening test rather than a specific problem or monitoring for disease recurrence. Screening was defined as offering the PSA to asymptomatic men perhaps as part of a routine examination or during a problem visit not related to the prostate or prostate cancer. The total number of men aged 40 or older was 930. Of that number, 532 had heard of the PSA test. This number was reduced to 369 men who had undergone a PSA test. For 47 men, the reason was not related to screening, that is, it was for a specific problem or follow-up (including 31 men who reported having been diagnosed with prostate cancer). The final sample size for the study in which men were specifically asked the question, Did the doctor discuss the advantages and disadvantages of the PSA test before doing it? was 322. Some analyses may have had fewer than 322 due to missing data, refused, and don t know responses. Table 1 shows the number of men in the sample by inclusion criteria. Data Collection The NHIS provided several contingency questions related to prostate cancer test use and screening. For eligibility, men aged 40 or older had to answer

4 158 American Journal of Men s Health / Vol. 2, No. 2, June 2008 Table 1. Inclusion Criteria for non-hispanic African American Men Aged 40 or Older (N = 322) Total Number Inclusion Criteria Yes No Remaining in Study Sample African American men aged 40 or older 930 Heard of a PSA test Had at least one PSA test Most recent PSA test was related to a routine examination or screening a 322 a. The reason for the most recent prostate-specific antigen (PSA) test was related to a specific problem or follow-up and not related to screening. positively, Have you ever heard of a PSA or a prostate-specific antigen test? Those who answered yes were asked the question, Have you ever had a prostate-specific antigen test? Those who answered yes were then asked the question, Did the doctor discuss the advantages and disadvantages of the PSA test before doing it? This last question was asked specifically of men regarding their most recent PSA test. Analysis The NHIS 2000 study used a complex sample design involving stratification, clustering, and multistage sampling (National Center for Health Statistics, 2002). This design incorporated sample weights that reflected the standard population of the United States in 2000 (National Center for Health Statistics, 2002). Therefore, the Survey Data Analysis statistical program, SUDAAN (Shah, Barnwell, & Bieler, 2004), was used for the analysis. Both univariate and multivariate analyses were performed. For univariate analyses, physician-patient discussions were categorized by each independent variable to calculate percentages of African American men by selected characteristics. Only those significant associations were presented. Multivariate analyses were performed using logistic regression. An initial model included all patient characteristics and physician-patient prescreening discussions. The final model included only those variables that supported parsimony. Within the logistic regression procedure, general linear contrasts were used to make comparisons among variable attributes and reference levels. The Wald F test was used to assess overall statistical significance of each covariate in the model. Adjusted odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were examined for overall statistical significance. The full multivariate model included all of the covariates in Table 2. Through backward exclusion, one variable was dropped during each analysis that had the highest probability values (p values), and the model was rerun. The final reduced model adjusted for and included those variables in the analysis. Variables for which the 95% CIs did not include 1.00 (p.05) are shown in Table 5. Results A total of 322 African American men were included in the sample (Table 2). The largest portions of men were aged 50 to 64 (n = 147, 44.2%) and were high school graduates (n = 91, 29.5%) or had some college/technical school training (n = 96, 30.0%). Majorities of these men lived in the South (n = 188, 59.7%), resided in a metropolitan statistical area (n = 279, 87.8%), and were married (n = 170, 68.6%). Also, most of these men reported some type of health insurance coverage (n = 298, 93.5%) and a usual source of health care (n = 301, 94.6%). A majority of African American men perceived themselves to be at low risk for getting cancer (n = 193, 69.4%), and a majority of these men reported a low occurrence of cancer in their families (n = 242, 80.0%). Almost 90% (n = 284, 88.9%) of these men reported no family history of prostate cancer. The majority had undergone a PSA screening test within the past 2 years (n = 270, 85.7%), and their most recent screening test was suggested or initiated by their physician (n = 243, 74.6%). Almost three fourths (n = 240, 73.8%) of African American men aged 40 or older reported having discussed the advantages and disadvantages of the PSA with their physicians before the physician ordered their most recent test (Table 3). Table 4 shows the unadjusted population-weighted percentages of African American men who had discussions with their physicians by selected variables with significant associations. Those men with the highest percentages of family incomes above the poverty threshold were less likely than those men with family incomes less than 200% above the poverty threshold to have a physician-patient discussion about the advantages and disadvantages of the PSA test (n = 61, 62.6%). Men who reported excellent health were more likely than those men in fair or poor health to have had physician-patient discussions (n = 60, 87.3%). Men

5 Physician-Patient Discussions With African American Men About Prostate Cancer Screening / Ross et al. 159 Table 2. Characteristics of non-hispanic African American Men Aged 40 or Older Who Reported Having Had One or More Screening PSA Tests in the Past 2 Years, NHIS 2000 Survey (N = 322) a Sociodemographics n (%) b Health Care and Prostate Screening n (%) b Age, years (31.1) (44.2) (24.7) Education < High school graduate 80 (25.5) High school graduate 91 (29.5) Some college/technical school 96 (30.0) College graduate 49 (15.0) Family income as % poverty threshold <200% 80 (25.7) 200%-399% 120 (37.0) 400%-500%+ 61 (17.0) Unknown 61 (20.3) Region Northeast 57 (19.4) Midwest 46 (13.3) South 188 (59.7) West 31 (7.6) Resides in MSA Non-MSA 43 (12.2) MSA 279 (87.8) Marital status Married/living with partner 170 (68.6) Widowed 32 (6.1) Divorced or separated 83 (17.2) Never married 37 (8.1) Health insurance Not covered 21 (6.5) Covered 298 (93.5) Usual source of health care Yes 301 (94.6) No 21 (5.4) Reported health status Excellent 60 (17.8) Very good 77 (23.4) Good 109 (33.8) Fair or poor 75 (26.0) Family history of prostate cancer Yes 34 (10.1) No 284 (89.9) Perceived risk of getting cancer Low 193 (69.4) Medium 78 (23.1) High 122 (7.5) Perceived amount of cancer in family Low 242 (80.0) Medium 52 (13.8) High 19 (6.2) Who suggested the PSA test Individual or others 79 (25.4) Physician 243 (74.6) Had PSA test within past 2 years Yes 270 (85.7) No 50 (14.3) Note: PSA = prostate-specific antigen; NHIS = National Health Interview Survey; MSA = metropolitan statistical area. a. Excluding men who had not heard of the test or had missing information. Categories that add up to less than 100% are due to missing data. b. Adjusted for the NHIS sampling methods and weighted to the U.S. Census who had undergone a screening PSA test in the past 2 years were more likely than others to have had a discussion with their physician about the advantages and disadvantages of the test (n = 268, 77.2%). In the multivariate analysis (Table 5), which adjusted for all other variables in the model, African American men who reported excellent rather than fair or poor health had more than 3 times the odds (OR = 3.69, CI = ) of having a discussion with their physician about the advantages and disadvantages of their most recent PSA screening test. Physician suggestion to have a PSA screening test was associated with having had physician-patient discussions (OR = 2.14, CI = ). Those men who reported having had a recent PSA screening test had increased odds of having had a physician-patient discussion (OR = 3.29, CI = ). Finally, there was borderline significance with health insurance Table 3. Frequency of Physician Discussions Regarding the Advantages and Disadvantages of the PSA Test for non-hispanic African American Men Aged 40 or Older Who Reported Having Had One or More Screening PSA Tests, NHIS 2000 Survey (N = 320) Physician Discussions About PSA Test n % a Yes No Note: PSA = prostate-specific antigen; NHIS = National Health Interview Survey. a. Adjusted for the NHIS sampling methods and weighted to the U.S. Census coverage and physician-patient discussions (p =.051). Those men who had some type of health insurance coverage rather than those men without some type of

6 160 American Journal of Men s Health / Vol. 2, No. 2, June 2008 Table 4. Percentage of non-hispanic African American Men a Aged 40 and Older Who Reported Physician-Patient Discussions Regarding the Advantages and Disadvantages of the PSA Test by Selected Characteristics, NHIS 2000 Survey (N = 322) Physician-Patient Discussions Characteristics n % b 95% CI c p Value d Family income as % poverty threshold <200% ref 200%-399% %-500% Unknown Reported health status Excellent Very good Good Fair or poor ref Had any PSA test in the past 2 years No ref Yes Note: PSA = prostate-specific antigen; NHIS = National Health Interview Survey; CI = confidence interval. a. Excluding men with prostate cancer. b. p value for a Wald chi-square main effect test. c. Adjusted for the NHIS sampling methods, weighted to the U.S. Census 2000, and adjusted to the distributions of all factors in Table 1. health insurance coverage had decreased odds of having had a discussion with their physician (OR = 0.32, CI = ). Discussion In the NHIS 2000, a majority (n = 240, 73.8%) of African American men aged 40 or older reported having discussed the advantages and disadvantages of the PSA test with their physicians before the physician ordered the PSA test. This is higher than the 63% for the general population (McFall, 2006) and much higher than the 28% of African American and White men (Dunn et al., 2001). Perhaps it is helpful for both men and their physicians to identify those factors or subgroups of men that are associated with having or not having discussions with their physicians. A majority of the men perceived themselves to be at low risk of getting cancer in general (n = 193, 69.4%), and similarly, a majority of men reported a low occurence of cancer in their families (n = 242, 80.0%). African Americans in general and African American men in particular have the highest rates for most cancers in America (American Cancer Society, 2007). Overall, perceived risk among African American men was low, which is somewhat inconsistent with actual cancer rates among African Americans. For this study, excellent health status, physician suggestion to take the PSA screening test, having a recent PSA screening test (in the past 2 years), and possibly not having health insurance coverage were associated with physician discussions about their most recent screening test. Some research reports cite socioeconomic factors as the underlying cause for the prostate cancer health disparities. There are a myriad of social, cultural, behavioral, genetic, and other influences that may affect this disparity. The current study offers some insight to identify factors in addition to or outside of socioeconomic status related factors that may be important in physician-patient discussions such as reported health status. Perhaps cultural, contextual, social-psychological, and/or personality variables may help to explain the types of persons who are most likely to participate in physician-patient discussions or at least offer additional insight. These types of variables might be examined in future studies. If those men who reported excellent health status are having more physician-patient discussions, perhaps it is within the preventive health context. Also, perhaps these healthier men were younger and fell within the 10-year life expectancy screening recommendation

7 Physician-Patient Discussions With African American Men About Prostate Cancer Screening / Ross et al. 161 Table 5. Adjusted Odds Ratios From Final Reduced Logistic Model of Physician-Patient Discussions Regarding the Advantages and Disadvantages of the PSA Test for non-hispanic African American Men a Aged 40 or Older, NHIS 2000 Survey (N = 322) Physician-Patient Discussions Characteristics p Value b Odds Ratio 95% CI c Education.146 < High school (ref) High school graduate Some college or technical school College graduate and beyond MSA residence.082 Non-MSA (ref) MSA Health insurance coverage status.051 Not covered (ref) Covered Reported health status.004 Excellent Very good Good Fair or poor (ref) Who suggested taking the PSA test.022 Patient or other person (ref) Doctor suggested Had any PSA test in the past 2 years.010 No (ref) Yes Usual source of care.385 No (ref) Yes Note: PSA = prostate-specific antigen; NHIS = National Health Interview Survey; CI = confidence interval; MSA = metropolitan statistical area. a. Excluding men with prostate cancer. b. p value for a Wald chi-square main effect test. c. Adjusted for the NHIS sampling methods, weighted to the U.S. Census 2000, and adjusted to the distributions of all factors in Table 1. suggested by many of the major organizations in their guidelines (National Guideline Clearinghouse, 2005). These prescreening discussions were associated with having had a recent PSA screening test (OR = 3.29, CI = ). This could mean that there is more emphasis and practice on physicianpatient prescreening discussions that conform to the recommendations of some of the major organizations such as the American Cancer Society and the American Urological Association (National Guideline Clearinghouse, 2005). Noted also was the borderline significance of health insurance coverage. Physician-patient discussions were associated with those men who were not covered with some type of health insurance. Although there were low numbers in one cell (n = 21 for those not covered), this seems to suggest the opposite pattern of earlier findings (Ross et al., 2004; Swan, Breen, Coates, Rimer, & Lee, 2002). The current study sheds some light on IDM, in that some form of physician-patient discussions or interactions, a prerequisite for IDM, took place for most of the men. However, IDM is more complicated. The patient must understand the nature of the disease or condition being addressed and must comprehend the benefits, risks, limitations, alternatives, and uncertainties of the disease or condition (Rimer et al., 2004). Then the patient should consider his or her preferences and make a decision or begin a plan of action consistent with those preferences (Rimer et al., 2004). Also, the patient should understand the screening tests, weigh the pros and

8 162 American Journal of Men s Health / Vol. 2, No. 2, June 2008 cons of the tests, and believe that he has participated in decision making at the level desired (Rimer et al., 2004). The one question analyzed in this study falls short of IDM but involves the physician and patient in some form of interaction. There were some limitations of this study. Due to inclusion criteria, some questions were contingent on affirmative responses to prior questions, reducing the sample size in the analysis. Another limitation is the reliance on self-reports of PSA test use (Chan, Vernon, Ahn, & Greisinger, 2004). Some men may underestimate the amount of time since their last PSA test (Gordon, Hiatt, & Lampert, 1993), men may have been given a battery of tests and perhaps were not told what they included, and there may have been a potential bias in misreporting that can vary by many social and personal characteristics (Dunn et al., 2001; Volk & Cass, 2002). The major question used in the study, Did your doctor discuss the advantages and disadvantages of the test before giving it? was asked only of men s last or most recent PSA screening test. If the men had additional prior PSA tests, there is no information on whether physician-patient discussions took place. An additional limitation is the possible bias in the question. Not all physicians discuss equally the advantages and disadvantages of the PSA test. Studies tend to suggest that physician-patient discussions often match physician beliefs and experiences about PSA screening and testing, and some discussions may encourage or discourage the test (Cooper et al., 2004; Dunn et al., 2001). This may be especially true for African American physician discussions with their African American patients. Of African American physicians surveyed, almost all (39 of 41 primary care physicians) recommended screening to their African American patients (Stroud, Ross, & Rose, 2006). An additional limitation was that there was no definitive information on whether the physician was a primary care physician or a specialist. Recommendations by specialty type may be quite different (Fowler et al., 1998). Perhaps most of these physicians were in primary care, as specialists often rely on primary care physician referrals; however, this information is not available from the data. Finally, little is known about the length of time and the nature of the discussion, that is, if the physician engaged the patient in meaningful discussion, if the patient desired to participate in the discussion, and so on. The study also has several strengths. The study uses data from a nationally representative sample with an overall response rate of 72.1% (National Center for Health Statistics, 2002). The study takes advantage of the oversampling of African Americans so that independent analyses can be conducted and general comparisons with other groups can be made. Findings from the current study offer some information about correlates of physician-patient discussions among African American men. The major question that was used, Did the doctor discuss the advantages and disadvantages of the PSA test before doing it? referred to the last or most recent PSA test, as many men reported more than one test. Perhaps it may be easier for men to remember their most recent PSA test and the reason for it. This may have improved the clarity and reliability of the question. This study clarified the difference between overall PSA test use and screening. Screening gives a clearer picture of PSA test use among asymptomatic men and not those men who took the test to monitor disease or went to the physician for a specific health problem. African American men who were not having discussions with their physicians tended to be in fair or poor health, were not getting suggestions from their physicians to take the screening test, had not had a screening PSA test in the past 2 years, and had health insurance coverage. The borderline association between those men not covered with health insurance reporting more doctor discussions is somewhat surprising. However, this finding reflects a similar but nonsignificant pattern reported when examining men from the general population (McFall, 2006). Research by Stroud et al. (2006) reported that inasmuch as it is often more difficult for males in general (and African American males in particular) to interact with the health care system, physicians used opportunistic counseling to engage men into prostate cancer discussions during unrelated office and other rare visits. Possible interventions might focus on these groups to increase awareness and knowledge and possibly assist with their decision making regarding the PSA screening test. Some of the goals of Healthy People 2010 are to decrease risk and mortality for all cancers including prostate cancer, whereas an additional goal is to reduce health disparities among groups (U.S. Department of Health and Human Services, 2000). Findings from this study showed that physicians had prescreening discussions with most of their African American male patients regarding their most recent PSA test. This seems to be at least a first step toward the recommendations and suggestions of the major medical organizations and possibly a beginning

9 Physician-Patient Discussions With African American Men About Prostate Cancer Screening / Ross et al. 163 step toward IDM or SDM. Future studies may wish to examine the nature of physician-patient discussions to explore if they are more pro-screening, antiscreening, or equally balanced. These studies (where possible) might examine physician discussions over time to note if more or fewer physician-patient discussions are taking place. Future studies might gauge whether some type of IDM or SDM is taking place as physicians interact with their patients about prostate cancer and screening. Acknowledgments Funding for Shaw University researchers was provided by Department of Defense Grant W81XWH Shaw investigators were also supported in part by the DHHS Agency for Healthcare Research and Quality Grant R24HS and the National Institutes of Health, National Center on Minority Health and Health Disparities Grants R24MD and P60 MD References Agho, A. O., & Lewis, M. A. (2001). 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10 164 American Journal of Men s Health / Vol. 2, No. 2, June 2008 Swan, J., Breen, N., Coates, R. J., Rimer, B. K., & Lee, N. C. (2002). Progress in cancer screening practices in the United States: Results from the 2000 National Health Interview Survey. Cancer, 97(6), Tannor, B. B., & Ross, L. E. (2006). Physician-patient discussions about prostate-specific antigen test use among African-American men. Journal of the National Medical Association, 98(4), U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. Washington, DC: Author. Volk, R. J., & Cass, A. R. (2002). The accuracy of primary care patients self-reports of prostate-specific antigen testing. American Journal of Preventive Medicine, 22(1),