Using a national survey with sufficient numbers of AA PCPs to enable accurate estimates for both AA and non-AA PCPs, we found that the magnitude of the difference between AA PCP and non-AA PCP responses was <10% for most questions. However, we also identified a small number of questions with differences ≥ 10% in magnitude and P-values ≤0.0002, values that persisted after adjustment for factors such as the proportion of AA patients in the PCP practices.
Prior to the current study, little quantitative data was available concerning differences in prostate cancer screening practices between AA and non-AA PCPs. Focus groups have been conducted, but involving relatively small numbers of PCPs.6
The focus group reports recommended additional research with larger numbers of PCPs in order to confirm the findings of their studies.
The current study results are generally consistent with those from previous focus group studies,6
but go beyond those studies by quantifying the magnitude of the differences and providing additional insights. For example, in the AA focus group study, most physicians indicated that they did not use any educational materials because the available materials were of poor quality and the viewpoints expressed were not appropriately balanced.7
In the current study, the proportion of AA PCPs providing patients with supplementary educational materials was relatively small, but the proportion of AA PCPs providing educational materials was higher than in non-AA PCPs.
In both the AA PCP focus group study7
and the current national survey, AA PCPs reported higher proportions of AA patients. These results are consistent with studies suggesting that patients from specific race and ethnic groups, including AA patients, may preferentially seek care from PCPs of their own race or reside in areas mostly served by AA PCPs.2
It is important to note that AA physicians comprise an important source of healthcare for AA patients.2
The 2007–2008 survey does not provide a definitive answer as to why AA PCPs reported more frequently than non-AA PCPs that their HME patients receive PSA tests. One hypothesis is that AA PCPs are more likely to screen AA patients in their practices because these physicians are more aware of the higher burden of prostate disease in AA patients.7
This greater awareness may have been obtained through either professional observation of patients or the personal experience of friends or family members diagnosed with prostate cancer.10
Some AA PCPs may also believe that the ratio of benefit to harm for screening is more favorable among AA men.7
During the duration of the current survey, the clinical considerations statement in US Preventive Services Task Force (USPSTF) recommendations included wording that may have permitted PCPs to come to conflicting conclusions regarding prostate cancer screening.11
The USPSTF summary recommendation stated that “the evidence is insufficient to recommend for or against routine screening” using PSA testing or DRE.11
In contrast, some PCPs may have concluded from this statement that PSA tests should not be performed, particularly because of the USPSTF clinical consideration statement that “screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cases.”11
Another possibility is that some PCPs may have concluded that PSA testing was permissible, particularly because of the USPSTF clinical consideration statement that “if early detection improves health outcomes, the population most likely to benefit from screening will be men 50 to 70 years of age who are at average risk and men older than 45 years of age who are at increased risk (African-American men and those with a first-degree relative with prostate cancer).”11
The reported difference by PCP race in the frequency that their HME patients received PSA tests may have also been influenced by factors that were not addressed in the 2007–2008 questionnaire. For example, the questionnaire did not include information regarding PCP personal health practices, such as physical activity, diet, drinking habits, and smoking habits.10
In a different study of prostate cancer screening practices reported by US medical students, personal health practices confounded the association between the student’s race and PSA screening frequency.10
In that study, no statistically significant relationship between the student’s race and the frequency of offering PSA counseling was found after adjusting for the student’s personal health practices.10
Most PCPs agreed or strongly agreed that providing PSA testing to average risk patients helped protect them from medical malpractice claims. PCP concern regarding legal liability for delay in diagnosis has been suggested as one of the potential factors contributing to the common use of PSA testing in the US.12
Additional research is needed to test this hypothesis.13
A study has reported on whether PCPs changed their prostate cancer screening behavior before, during, and after one of the PCPs in their community was sued for using shared decision making rather than PSA testing.13
This study concluded that PCPs in that community continued to use shared decision making and to let patients decide whether to be screened, but the use of PSA-testing increased.13
In the current study, medical malpractice concerns appeared less influential for AA compared with non-AA PCPs. The reasons for this difference are not known.
The current study has several strengths. First, the questionnaire content was developed using a broad range of methodologies including literature reviews, PCP focus groups, and pilot testing of the survey instrument.5
Second, the study included relatively large numbers of AA PCPs, which enabled a more detailed examination of practice differences by PCP race. Third, questions with larger (≥ 10%) differences had a chi-square P
-value of ≤0.0002, reducing the likelihood of false positives that may have been observed by random chance if multiple questions were evaluated statistically.
The current study also has limitations. First, although survey response rates were similar for AA PCPs and non-AA PCPs, more than 40% of PCPs in both groups were nonrespondents. These response rates are consistent with previous observations that physicians often may be less likely than other groups to respond to mail surveys.14
For the current survey, the prostate cancer screening practices of PCP nonrespondents is unknown.15
Second, we dichotomized variables in order to simplify the analysis and interpretation of results, and this simplification may have resulted in loss of some information from the original multiple categories.16
Third, the survey results were not validated by chart review or patient interviews.17
Fourth, from the perspective of current public health practice implications, an unknown is the extent to which current PCP practice patterns may be different from those in the 2007–2008 survey due to changes over time in PSA screening recommendations.11
For example, in 2012, the USPSTF recommended against performing PSA-based screening for prostate cancer in all men because there was “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”19
The 2012 USPSTF recommendations for AA men were the same as those for non-AA men.19
These recommendations have been controversial.20
In addition to several other objections, critics argue that the USPSTF underestimated the benefits and overestimated the harms of PSA screening, particularly for higher risk populations such as AA men.20
An updated PCP survey is necessary to determine current practice patterns and to evaluate whether PCPs are following the 2012 USPSTF recommendations or alternative, more recent recommendations by others.19