Prostate cancer screening and PSA test use, in particular, are complex issues. Disagreement surrounding screening criteria and the efficacy of the PSA test will continue until the benefits of testing are settled. Our finding that about 80% of PCPs, or nearly 76,000 nationally, reported that they routinely discuss prostate cancer screening to involve patients in the decision about screening with all age-appropriate male patients confirms findings of a recent smaller study. The study, which included 35 FP physicians and 28 general internists, reported that 79% of PCPs engaged in prescreening discussions with their patients.10
Our findings also showed that 64.1% (representing 56,137 nationally) of PCPs that engage in discussions reported that their usual policy when discussing PSA testing with patients was to talk the patient into getting the PSA test.
In a qualitative study, researchers divided U.S. PCPs into two groups on the basis of their prostate cancer screening practices: “routine screeners” who screened their patients regularly on the basis of their experience and belief in the benefit of PSA screening, and “non-routine screeners” who did not do so because of what they believed to be a lack of scientific evidence documenting the benefit of PSA screening.17
Our study found evidence of both patterns; higher percentages of those PCPs who encouraged the PSA test as well as physicians who tended to remain neutral or discourage the test. The 349 (34.4%) PCPs who remained neutral may suggest that some level of informed, or possibly shared, decision-making about prostate cancer screening is taking place between physicians and patients. If so, this behavior is in accordance with recommendations of the major medical and public health organizations (including the new 2010 American Cancer Society recommendation1
) that physicians discuss the possible benefits and risks of prostate cancer screening with patients before ordering the screening tests.4
However, our results did not indicate the content of these discussions.
In the current study, PCPs who described themselves as having a great deal of knowledge about the prostate cancer screening guidelines were more likely to involve their patients in discussions about screening (than PCPs with no or little knowledge of the screening guidelines) but were no more likely to encourage them to be screened. This finding is consistent with Cooper and associates (2004) who found that “non-routine screeners” gave no recommendation but rather discussed the implications of screening, tended to rely more on scientific evidence, tended to be more knowledgeable of the prostate cancer screening guidelines (than “routine screeners),” and explained that the benefit of PSA screening has not been proven.17
In a study of African American PCPs, 98% reported offering the PSA test to asymptomatic non-African American men at around 50 years of age and to asymptomatic African American men 5–10 years earlier.18
Most reported feeling that the seriousness of prostate cancer outweighed the potential limitations of screening and the risks of side effects from treatment.18
In another study,17
African American physicians reported high levels of screening. Few comprehensive studies regarding prostate cancer screening have been conducted among African American PCPs. Our finding, that non-Hispanic black PCPs were more likely than non-Hispanic white PCPs to encourage their patients to be screened, may reflect the underlying sentiment identified in a previous study that suggested that African American PCPs were more concerned about the high prostate cancer burden among African American men.18
Results from the National Survey of Medical Decisions showed that a majority of physicians (about 70%) discussed prostate cancer screening with their patients and a majority (73%) recommended that patients take the test,19
as did our analysis. However, this study offered little information on factors related to these practices. In an international study of general practitioners, the likelihood of physicians screening their patients for prostate cancer was associated with being older, having practiced longer, being female, and being less knowledgeable about PSA efficacy.20
In our study, in addition to finding the likelihood that PCPs would discuss prostate cancer screening with their patients (first outcome) to be associated with PCP race, we also found it to be positively associated with weekly patient volume, self-perception of knowledge about the screening guidelines, and type of practice of the PCP. This suggests the importance of both individual and practice-level factors in prostate cancer screening practices among PCPs.
Our study provides information on PCP characteristics that are not associated with discussing prostate cancer screening with patients. They include white race, having lower weekly patient volumes, and having little knowledge about the prostate cancer screening guidelines. PCPs who did not have a discussion policy to talk the patient into getting the PSA test (or were more neutral or discouraged testing) tended to be non-Hispanic white, with fewer years practicing medicine, in multi-specialty group practices, with lower patient volumes, and spending fewer hours per week in direct patient care. This information is timely due to the current screening guidelines from most organizations that recommend that PCPs discuss prostate cancer screening with their patients and utilize some form of individual or shared decision-making.6
Strengths of our study included use of data from the largest, most comprehensive survey to date of prostate cancer screening practices, representing nearly 95,000 U.S. PCPs. This study oversampled African American PCPs, about whose screening practices relatively little is known. Our analyses of the relationship between multiple factors associated with PCP attitudes and behaviors about prostate cancer offer information that could not be obtained from earlier qualitative studies.17,18
Limitations to our study included our reliance on non-validated data derived from the self-reports of PCPs,21,22
and our inability to conduct meaningful analyses of prostate cancer screening behaviors among PCPs of other races dues to the very small numbers of these groups in our study sample. The majority of physicians categorized as other race, self-identified as Asian. Therefore, our findings may reflect this group of PCPs more than others. Also, depending on whether the “policy” when discussing PSA testing with patients was formal or informal, physicians may have had different levels of flexibility in their recommendations. The survey instrument did not capture this distinction.
Finally, this study was conducted before the newer American Cancer Society prostate cancer screening guidelines (2010) were released, thus results may not adequately reflect PCPs following of current screening guidelines. Due to disagreements over prostate cancer screening efficacy, policymakers, clinicians, and scientists struggle with medical issues such as prostate cancer screening. The current study shows that there is a difference in what major organizations such as ACS and USPSTF recommend and what clinicians actually do in practice. The clinical decision to encourage patients to undergo screening, remain neutral, or discourage screening can vary based on PCP individual as well as practice-related factors. As findings from randomized trials continue to emerge, perhaps better clarity and direction about screening and its implications will follow.
Future studies should examine both African American and other minority race PCPs in separate analyses to describe specific attitudes and behaviors of these groups related to prostate cancer. A future study might also examine in more detail relationships between the amount of time spent with patients in such discussions and the PCP screening recommendation. This would serve to enlighten both researchers and clinicians about which individual or practice-related factors are related to time spent with patients. Our findings add clarity to results from earlier qualitative studies of PCP practices related to prostate cancer screening17,18
and provide additional information on associations with PCP- and practice-related factors. We hope that these results prove valuable to researchers and clinicians and help guide the development and implementation of future prostate cancer screening interventions in the U.S.