Abstract
Background
Guidelines for prostate cancer (PCa) screening recommend physicians to have an informational discussion with patients. At the time of biopsy, patients should be informed of their heightened PCa risk, particularly African Americans (AA) who have significantly higher diagnostic and mortality risk. We tested predictors of patients’ estimation of their likelihood of having PCa at the time of biopsy.
Methods
A convenience sample of AA (n = 207) and white (n = 271) biopsy patients was surveyed at the time of prostate biopsy. Participants gave likelihood estimations of having PCa and data on their socio-demographics, health, clinical status, and general and PCa-specific anxiety. Binary logistic regressions tested for predictors of the patients’ estimations and biopsy results.
Results
Fifty-one percent of AA men answered that they had a ‘0%’ likelihood of having PCa versus 19% of whites, whereas 57% of AA men had abnormal biopsies compared with 42% of whites. In logistic regressions, predictors of patient answers of 0% chance of PCa were AA ethnicity (OR = 4.50; p <0.001), lower cancer-specific anxiety (OR = 0.93; p <0.01), less education (OR = 2.38; p <0.05), and less urinary disturbance (OR = 0.70; p <.05). In a second regression, AA patients trended towards higher positive biopsy rates (OR = 1.43; p = 0.17).
Conclusions
At biopsy, AA more often estimated their likelihood of PCa as 0%, despite higher risks. Reasons for these low estimates and their potential contribution to poor treatment outcomes of AA patients require further investigation.
Keywords: cancer, oncology, African American, biopsy, prostate
Introduction
Prostate cancer (PCa) is the most common non-skin cancer diagnosed in men and disproportionately affects African Americans (AA) with an estimated 35,110 new cases among AAs in 2011 [1]. Given the complexity regarding information on the risks, benefits, and appropriateness of PCa screening, guidelines emphasize the importance of having an informed discussion with patients before performing a prostate-specific antigen (PSA) test or digital rectal examination (DRE) [2–6]. When PSA test or DRE results justify further scrutiny, physicians typically proceed to recommend a prostate biopsy that is performed by a urologist. Patients’ needs for adequate information about PCa as they progress through diagnosis and treatment appear to be even more important in light of new evidence showing that they have unrealistic expectations of their post-prostatectomy urinary and sexual health [7]. Furthermore, recently observed socio-cultural and ethnic differences in psycho-emotional adjustment illuminate questions about how men’s emotions and cognitions bear on their expectations about cancer diagnoses prior to biopsy and their ultimate health outcomes [8,9].
At the time of biopsy, the overall detection rate for PCa is generally observed to be 20–30%, and as high as 33% in AA men [10,11]. Therefore, men sent for biopsy with an elevated PSA or abnormal DRE are expected to be informed of their heightened risk for PCa. Whether these patients are sufficiently informed to make decisions about treatment (if diagnosed with PCa) or future biopsies (if results are normal) is unclear. In the past, appreciable focus has been put on the knowledge, beliefs, emotions, and attitudes that determine whether a patient pursues screening for PCa [12–15]. However, we are unaware of any examination of patients’ estimations, especially AAs, about their likelihood of a PCa diagnosis at the time of prostate biopsy. Such estimations of one’s own likelihood could be important in determining how they pursue treatment in the future, how accurate their expectations are regarding treatment outcomes, as well as a measure of the efficacy of physicians and care providers for appropriately informing these patients.
Proscriptively, medical care has moved towards a paradigm in which patients should be informed participants in their own healthcare. Last year, attendees to an international seminar entitled ‘The Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care’ articulated the detailed requirements in the Salzburg statement on shared decision making [16]. More specifically, in PCa care, some have called to make screening a teachable moment about its importance and uncertain risk [2,17]. But recent evidence shows that patients do not have realistic expectations of quality of life after a prostatectomy [7]. The theory of planned behavior (TPB) provides a framework for how psychological variables such as disease expectations impact health behavior intentions and actions [18]. Important work indicates that the TPB is useful in predicting PCa screening behavior among high PCa-knowledged patients [19]. However, less is known about the decisions of inadequately informed men at the time of biopsy or the role of subjective personal risk beliefs in the health behaviors of patients who have come to clinic to obtain a prostate biopsy. The roles of both information and emotion appear important in risk perceptions and behavior [20]. Our own work shows that PCa anxiety is predictive of choosing to start androgen deprivation therapy [21]. The TPB can help to understand the previously mentioned results and determine the informational needs of different patient populations and how to meet them.
In particular, AA men receiving a biopsy need to be aware of their elevated risk of having PCa because of their higher incidence (1.6 times) and mortality (2.4 times) rates relative to whites [10,22,23]. This heightened risk implicates a genetic component that makes AAs more likely to have an earlier onset, more aggressive course, and a range of socioeconomic factors that often delay identification [23–33]. Furthermore, AA ethnicity is a significant predictor of PCa detection on biopsy, independent of other clinical markers [10,23]. Consequently, AA men in particular have a greater need to be accurately informed about their potential PCa diagnosis by the time of biopsy.
This study utilized a sample that was over 40% AA to collect patients’ estimates of their own estimated likelihood of having PCa at the time of biopsy and compared these estimates to their observed population rate of PCa. We also identified other patient characteristics that predict these patients’ estimates of having PCa. Specifically, we wanted to know what was predictive of an inaccurate estimation of one’s own risk. Separately, we tested the same variables to see what was predictive of an abnormal biopsy result among patients in our sample.
Materials and methods
As part of a larger project on health utilities conducted on site in a urology prostate biopsy clinic, a convenience sample of patients was recruited for in-person surveys at The University of Chicago urology clinic after completion of their prostate biopsies between September 2005 and July 2010. Sixty-five percent of biopsies were performed by one urologist and the remaining 35% by a second. All patients attending the clinic for biopsy were approached to participate by a researcher stationed in an exam room adjacent to the biopsy room. Patients were eligible for participation unless they had a known history of dementia or were not conversant in English. Only two patients were turned away for apparent cognitive disturbances and six for English language barriers.
Surveys were administered face to face immediately following the patient’s biopsy and clinical debriefing, but before the patient learned of his biopsy results. Thirty-four percent of approached biopsy patients consented to participate with the predominant reason for refusal being a lack of time. The study procedures were approved by the Biological Sciences Institutional Review Board.
Per regular clinic practice, patients were given a five-page prostate biopsy handout several days before the biopsy. It detailed the biopsy preparation, procedure, ramifications of results, potential need for retesting and for making a treatment decision. Some statements relevant to the patients’ potential for having PCa at that point in time include the following:
The pathologist will determine if there are cancer cells in your biopsy sample by examining it under the microscope. . … If cancer is present, the pathologist will also assign a Gleason grade.
Unfortunately, biopsies can occasionally miss detecting cancer. This is known as ‘false negative’ result. If your doctor still strongly suspects you may have prostate cancer (due to a very high PSA level, for example) or certain pathological findings (atypical and high grad pre-malignant cells), a repeat biopsy may be needed to help rule this out.
If the biopsy is positive, we will discuss the findings with you and schedule a clinic appointment to go over all treatment options available for your prostate cancer. . ..
The clinic intended the handout to help deliver the message that the patients had a significant likelihood of having PCa and that the purpose of the biopsy was to test for the presence of cancer. The urologist orally presented the information contained in the handout in an unstandardized and conversational fashion, and the patient was allowed to keep the handout.
The computer-based survey was part of a larger study of health-state utility elicitation that took approximately 25 min to complete. Following each patient’s biopsy, informed consent was obtained, and the survey was administered by a researcher in an adjacent examination room that provided quiet and privacy. The full survey consisted of socio-demographics (age, ethnicity, income, education level, marital status), self-rated current health (excellent, very good, fair, or poor), presence and severity of urinary incontinence and erectile difficulty [34], and current pain level (0–10 scale). The Vulnerable Elders Survey 13, a brief physical disability screen including six common activities, was included to measure physical disability [35]. A reported inability to do any of the six activities was scored as having a disability. The anxiety measures included the Hospital Anxiety and Depression Scale (HADS-A) [36] to measure general anxiety and the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) [37,38] to measure anxiety specific to PCa. Clinical data such as prebiopsy PSA score and primary treatment were extracted from medical records. A research assistant called participants on the telephone 2–4 weeks post-biopsy to ask some brief follow-up questions, including what treatment choice the patient made. These follow-up calls took approximately 2 min.
The primary outcome of interest was the answer to the question: ‘How likely do you believe it is that you have prostate cancer?’ Patients were provided with an 11-point scale ranging from 0 to 100% scale in 10%-point increments. A second outcome of interest was the actual abnormal biopsy results to compare this sample to known rates. No formal computation of needed sample size was performed prior to the initiation of this project because the data were collected as part of a larger project on health utilities. Furthermore, we knew of no data documenting patients’ self-provided estimates of having PCa at the time of a biopsy.
Rather than requiring a specific and accurate prediction of the observed population’s positive biopsy rate, we conservatively chose to consider any estimate above ‘0%’ as the criterion of accuracy. Binary logistic regression analysis was used to determine significant correlates of the participants answering a 0% likelihood of having PCa versus accurate ‘non-0%’ predictions. Many variables previously found to be predictive of an actual positive biopsy in a large AA and white-mixed sample were included [11]. Additionally, data were available on other variables that the research team expected to potentially affect the participants’ estimations of personal likelihood, which included experience with symptoms known to be associated with PCa, having a relationship with a significant other who might impact respondents’ expectations, and anxiety about disease. Patients who report experiencing symptoms or those who have or perceive to have a lower level of overall health might be more likely to estimate that they have PCa. Additionally, having a relationship with a significant other impacted expectations through conversations away from the clinic. As well, much psychological evidence indicates that risk perception is often based on ‘risk as feelings’ [39].
All variables hypothesized to influence the patients’ predictions of having PCa were entered together. The following socio-demographic characteristics were included: age, AA ethnicity (vs. whites), married or living as married (vs. not), education (categorical: (1) high school graduate or less, (2) some college to college graduate, (3) post-graduate and beyond), and annual income in four categories. The clinical and health variables of prebiopsy PSA score, disability (Vulnerable Elders Survey 13), any experience with erectile dysfunction in previous year (yes or no), amount of bother from urinary symptoms (4 categories: none, little, some, a lot), and self-rated current health were also included. A measure of PCa anxiety (MAX-PC), validated with AA, was also included in the model.
Additionally, a second logistic regression analysis was conducted on ‘positive PCa biopsy result’ versus negative (normal) using the same predictor variables as in the first analysis. This was carried out to compare which variables, from among those included in the previously described ‘0% predictions’ logistic regression analysis, were associated with an abnormal biopsy result (probable PCa). All analyses were performed using STATA software version 11 (College Station, TX).
Results
A total of 490 men completed the survey. In the sample, there were 207 AA and 271 whites, with an average age of 63.7 years (Table 1). Complete data were available for 325 participants for the first regression, including 152 AA patients and 173 white patients, to be entered in the regression analyses, with the most commonly missing variable being prebiopsy PSA, which was missing at random. There were 10 more participants with complete data (they were missing the PCa prediction question necessary for the first analysis) for the biopsy outcome regression for an n = 335, with 159 AA and 176 white participants.
Table 1.
Prostate biopsy patient characteristics (n = 478) valid% reported
| African Americans n = 207 | Whites n = 271 | p-value | |
|---|---|---|---|
| Age (mean ± sd) | 63.7 ± 8.3 | 62.3 ± 8.1 | 0.08 |
| Education | |||
| High school graduate or less | 81 (40) | 36 (13) | < 0.01 |
| Some College/college grad | 94 (46) | 101 (37) | |
| Graduate-level education | 30 (14) | 134 (50) | |
| Income | |||
| Less than $35,000 | 87 (49) | 33 (14) | < 0.01 |
| $35,001–$50,000 | 56 (32) | 60 (25) | |
| $50,001–$100,000 | 27 (15) | 93 (39) | |
| Over $100,000 | 8 (5) | 52 (22) | |
| Married or living as married | 122 (59) | 217 (80) | <0.01 |
| Have primary care doctor | 192 (93) | 246 (91) | 0.51 |
| Prebiopsy PSA (mean ± sd) | 8.9 ± 8.0 | 8.3 ± 16.8 | <0.01† |
| Erectile trouble within last year | 86 (44) | 94 (36) | 0.1 |
| Amount of bother with urination | |||
| None | 127 (64) | 129 (50) | 0.01 |
| A little | 34 (17) | 75 (29) | |
| Some | 27 (14) | 40 (15) | |
| A lot | 10 (5) | 16 (6) | |
| Self-rated current health | |||
| Poor | 5 (2) | 0 (0) | <0.01 |
| Fair | 59 (29) | 35 (13) | |
| Good | 99 (48) | 136 (50) | |
| Excellent | 44 (21) | 100 (37) | |
| Cancer-specific anxiety (MAX-PC) (mean ± sd) | 7.5 ± 7.1 | 7.6 ± 7.2 | 0.89 |
| Physically disabled | 62 (30) | 45 (17) | 0.001 |
PSA, prostate-specific antigen; MAX-PC, Memorial Anxiety Scale for Prostate Cancer.
Patients with missing data were not significantly different from those included in the analyses on any socio-demographic, psychological, or clinical variable. Over half of the sample had a college degree or higher. Just over 20% had at least some physical disability. Although the men surveyed had recently completed the biopsy procedure, they indicated low amounts of pain on a 10-point scale (mean = 1.3 ± 2.1) at the time of the survey. The median prebiopsy PSA level was 5.6 (mean = 10.7 ± 14.0) with 82% having levels over 4.0 mg/ml and 19% having levels at or above 10.0 ng/ml. After truncating the three most extreme outliers among PSA values, AA and white men did not differ significantly in their PSA levels.1 The overall sample had moderately low levels of both general (HADS-A; mean = 3.7 ± 3.6) and PCa-specific anxiety (MAX-PC; mean = 7.4 ± 7.1), and these measures were significantly correlated (r = .66, p <0.001).
Most patients underestimated their possibility of having PCa, both compared with national averages and with observed likelihood for their ethnicity. Almost 51% of the AA men versus 18.7% of whites indicated that they had a 0% likelihood of having cancer (p <0.001). Logistic regression analysis revealed that AA were four and a half times more likely (OR = 4.50; p <0.001) than whites to indicate they had 0% likelihood (Table 2). Additionally, lower education level increased the odds of a 0% answer (OR = 2.38; p = 0.012), as did less bother from trouble urinating (OR = 0.70, p <0.05). With HADS-A general anxiety and MAX-PC PCa anxiety significantly correlated and conceptually related, it was decided that PCa-specific anxiety was of greater importance to include, and it was found to be predictive such that lower anxiety predicted an estimation of 0% (OR = 0.93, CI 1.21–4.67, p <0.05).2 Prebiopsy PSA level, urinary symptoms, and erectile dysfunction were not statistically significant correlates of predicting a 0% likelihood of having PCa. Within the subsample of men (n = 193) receiving positive biopsy results, almost 35% indicated that there was a 0% chance they have PCa, consisting of 53% (n = 106) AA versus 14% of (n = 87) whites (z = 5.65, p <0.001).
Table 2.
Multivariate logistic regression: correlates of indicating a ‘0% chance’ of having prostate cancer
| Odds ratio | p-value | 95% CI | ||
|---|---|---|---|---|
| Socio-demographics | ||||
| African American (vs white) | 4.50 | 0.000 | 2.46 | 8.24 |
| Age | 0.97 | 0.068 | 0.93 | 1.00 |
| Education | ||||
| High school graduate or less (vs college) | 2.38 | 0.012 | 1.21 | 4.67 |
| College-level | ref | ref | ||
| Graduate Education (vs College) | 1.02 | 0.948 | 0.51 | 2.06 |
| Annual income | 0.90 | 0.534 | 0.64 | 1.26 |
| Married (vs not married/partnered) | 1.00 | 1.000 | 0.53 | 1.87 |
| Clinical variables | ||||
| Prebiopsy PSA Level | 1.00 | 0.888 | 0.97 | 1.02 |
| Current health | 0.94 | 0.773 | 0.62 | 1.42 |
| Erectile trouble within last year (vs. not) | 1.20 | 0.549 | 0.66 | 2.17 |
| Amount of bother with urination | 0.70 | 0.033 | 0.50 | 0.97 |
| Physically disabled | 0.92 | 0.821 | 0.46 | 1.87 |
| Cancer-specific anxiety (MAX-PC) | 0.93 | 0.002 | 0.89 | 0.98 |
CI, confidence interval; PSA, prostate-specific antigen; MAX-PC, Memorial Anxiety Scale for Prostate Cancer.
In considering the second logistic regression on biopsy results, it is important that the prevalence of positive biopsy was significantly higher for AA than white patients (57% vs. 42%; p <0.01). In controlling for the other factors, being AA (OR = 1.43; p = 0.17) trended towards higher odds of a positive biopsy but was nonsignificant. Higher prebiopsy PSA level (OR = 1.03; p <0.05) related positively and older age (OR = 1.03, CI; p = 0.06) trended towards having an abnormal biopsy, whereas higher self-rated health status (OR = 0.70, CI 0.49–1.00; p <0.05) related to a decreased likelihood (Table 3). Anxiety, urinary symptoms, and erectile dysfunction were not correlated with biopsy results.
Table 3.
Multivariate logistic regression: correlates of abnormal biopsy results
| Odds Ratio | p-value | 95% CI | ||
|---|---|---|---|---|
| Socio-Demographics | ||||
| African American (vs white) | 1.43 | 0.168 | 0.86 | 2.38 |
| Age | 1.03 | 0.062 | 1.00 | 1.06 |
| Education | ||||
| High school graduate or less (vs college) | 0.84 | 0.563 | 0.46 | 1.52 |
| College-level | ref | ref | ||
| Graduate education (vs college) | 0.69 | 0.194 | 0.39 | 1.21 |
| Annual income | 1.11 | 0.461 | 0.84 | 1.47 |
| Married (vs not married/partnered) | 1.08 | 0.773 | 0.62 | 1.88 |
| Clinical variables | ||||
| Prebiopsy PSA level | 1.03 | 0.045 | 1.00 | 1.07 |
| Current health | 0.70 | 0.049 | 0.49 | 1.00 |
| Erectile trouble within last year (vs. not) | 0.78 | 0.336 | 0.47 | 1.29 |
| Amount of bother with urination | 0.96 | 0.732 | 0.74 | 1.23 |
| Physically disabled | 1.07 | 0.835 | 0.58 | 1.95 |
| Cancer-specific anxiety (MAX-PC) | 1.00 | 0.84 | 0.97 | 1.04 |
CI, confidence interval; PSA, prostate-specific antigen; MAX-PC, Memorial Anxiety Scale for Prostate Cancer.
Discussion
Our key finding is that, at the time of their prostate biopsies, a high percentage of men, particularly AA, significantly underestimate their likelihood of having PCa. Most concerning is that over half of the AA men indicated that their likelihood of PCa at 0% that is grossly inaccurate for this sample in which the abnormal biopsy rate was 57% (versus 42% for whites). Patients’ underestimation of their likelihood of having PCa is perhaps unsurprising, but the large proportion answering ‘0%’ is especially troublesome, given the elevated risk of PCa for anyone referred for a biopsy. Overall, 54% of the men (60% AA and 39% whites) who answered 0% received positive biopsy results. This finding is even more puzzling given that the five-page handout discussed with the physician prior to the biopsy details the possibility of a positive biopsy and the potential necessity for a second biopsy if the doctor still suspects that the patient has PCa. The fact that after controlling for education and other socio-demographic and health variables, AAs were 4.5 times more likely than whites to estimate a 0% likelihood of having PCa, demonstrating that this high risk group that is more often negatively impacted by this disease makes inaccurate predictions at an even higher rate. In view of the overall high level of education of our sample, that over 90% of participants has a primary care physician, the current guideline emphasis on counseling prior to PSA screening, and the clinic’s implementation of an informational handout and discussion, it is rather surprising and potentially clinically harmful that these men do not possess more accurate information about their likelihood of having PCa diagnosed at biopsy.
In a binary logistic regression model of a positive biopsy result using the same independent variables as the prediction model, AA trended towards significance demonstrating that AAs were at least as likely to be diagnosed with PCa if not more and, hence, putting greater significance on the results found with the first model. Older age, which was observed with a larger, multi-institution study examining predictors of abnormal biopsy results, also trended towards positive prediction of abnormal biopsy results [11]. As expected, prebiopsy PSA level was correlated with positive biopsy results in our sample. Overall, these results made sense given what is known about PCa and they demonstrated that risk factors predictive of having PCa were the same in our sample, as those reported elsewhere.
Patients in our sample exhibited a generally low degree of PCa anxiety, and lower MAX-PC scores were predictive of making a positive biopsy estimation of 0%, suggesting that the relationship between affect and risk, supported by much of the psychological literature on risk perception, is present in the biopsy patients [39]. This finding could reflect lower patient concern about their personal PCa risk stemming from a misunderstanding of their risk. AA men, known to be at greater PCa risk [22] and who showed a higher incidence in our sample, were significantly more likely to underestimate their likelihood of having PCa as well as have lower MAX-PC scores. AAs’ lower estimations of having PCa, even after a biopsy referral physician consultation, and informational handout should have alerted them to their higher risk of PCa, might stem from some of the same causes that lead to AA patients getting diagnosed later in the disease course [40]. For example, these risk beliefs could decrease their follow-up after receiving an abnormal biopsy result so that they only present later with symptoms and more advanced disease. Some evidence suggests that receiving abnormal biopsy results does not guarantee that patients follow up on physicians’ recommendations for further care [41]. Although having PCa-specific anxiety is associated with predicting that one has PCa, it does not predict actually having PCa in our sample. This suggests that there is some mismatch between the disease and anxiety such that those who are moderately anxious are frequently free of disease, whereas those who end up having PCa are low in anxiety. Further investigation is needed to clarify the reasons for the likely ‘mismatch’ between anxiety, likelihood estimations, and actual risks if we are to improve the clinical course of PCa screening, diagnosis, and treatment.
This study has some important limitations. It utilized a convenience sample in which all patients attending one clinic were approached, but only approximately one-third were consented for participation because detailed information was not available about each patient’s reasons for pursuing a prostate biopsy. Additionally, nothing was known about what other information was provided to patients by their physicians besides the biopsy handout and how the face-to-face consultation was conducted. And, although education level was accounted for, health numeracy was not, which convinced us to utilize a very conservative criterion for incorrect estimations (0%) [42]. Measuring years of education did not allow for a specification of the nature of the effect of schooling or cognitive aptitudes, and it has been observed that numeracy can be important in understanding health information [43,44]. It is necessary to incorporate more specific measures of cognitive skills and aptitudes in future investigations. Additionally, future research must include more detailed information on what has been shared with patients and will collect all cognitive variables potentially relevant to their prediction of biopsy outcome.
The timing of the data collection must be considered a potential and uncertain limitation of this study. It was necessary to acquire patients estimations of their PCa likelihood before they received their results, but collecting these estimates at the time of biopsy leads to the possibility of psychological morbidity affecting estimations. Although patient pain and anxiety were relatively low, it is possible that patients’ efforts to cope with the stress led them towards denial, and the results of one investigation demonstrate that AA PCa patients exhibit higher emotional well-being, and a lower percentage have clinically significant depressive symptoms compared with Caucasian men [8]. However, our results show that the groups have equal anxiety suggesting that this is not the driving force behind the higher proportion of 0% answers among AA patients.
Although the physician discussed the handout with the patient, it is not clear that this was carried out in a uniform fashion between patients. Additionally, it is unclear that patients reliably read the handout even though they were instructed to do so by the urologist, and it was provided for them to take home a week or more prior to their biopsy. The informational handout’s Flesch–Kincaid Grade Level Score is 10 and reading ease of 51.4, which might be challenging for some patients even though standard care practice was for the physician to discuss the handout and allowed the patient to ask any questions at their prebiopsy appointment.
Another question surrounds the psychological meaning of a patient making a ‘0%’ estimation of having PCa, which might reflect a lack of PCa knowledge, a poor understanding of probabilities, or unrealistic optimism. There is some evidence that a 50% rating of probability represents a ‘total uncertainty’, and many different scales and report methods have been used to collect the public and patients’ personal cancer risk estimates [45]. Consequently, we sought to take a conservative approach to dichotomize estimations between 0% and non-0% to test for predictors of extreme answers. These results are not presented as a full explanatory or predictive model of patient biopsy result estimates but suggest that this phenomenon requires further investigation.
Although much uncertainty surrounds the meaning of the results presented here, it is clear that these findings highlight the need for further investigation of biopsy patients’ thinking about their odds of having PCa. We know of no other data published to date with a significant number of AA patients that bears on the issue of patients’ understanding of their PCa risk at the time of biopsy.
Conclusions
This study’s principal finding is that AA men significantly underestimate their likelihood of being diagnosed with PCa at the time of biopsy, with over half indicating their risk as 0%. In light of recent evidence indicating that, at the time of treatment, men have unrealistic expectations of their urinary and sexual function after prostatectomy despite preoperative counseling; these data cast further doubt that informational conversations between physicians and patients are effective or reliably take place by the time of biopsy [7]. Given that evidence demonstrates that AA men show a greater, psycho-emotional resiliency to PCa than whites, a potentially negative side-effect of this fortitude could be formulating expectations that lead to poor preparedness [8]. Furthermore, it is uncertain that AA and white patients express anxiety in the same way as it has been found that AA are less likely to pursue psychological health services and associate shame, stigma, and denial with having negative emotion [46,47]. Resistance to negative affect might be related to unrealistic expectations, biased decision making, and consequently more objectively negative disease and treatment outcomes for AA men. Making sure that patients sufficiently comprehend information to make informed decisions is an important accompaniment to providing psycho-emotional support and protection against psychological morbidity.
Furthermore, it is not clear how indicative the unrealistic biopsy expectations our participants provided are of the thinking that men who are not presenting to a biopsy clinic but belong to an at-risk population and might even have had abnormal PSA test or DRE results. On a more general scale, these results suggest that men progressing through PCa screening, testing, and treatment are not well-informed or comprehending their clinical situations.
Achieving a better understanding of why AA biopsy patients provide unrealistic estimates of their own likelihood of having PCa will help identify breakdowns in the information exchange leading up to biopsy, provide more timely diagnoses, put patients in a more informed state to make decisions, and ultimately help improve outcomes for patients who are hit hard by PCa.
Acknowledgments
Glenn Gerber and Greg Zagaja, for patient recruitment. Eilis Karr, Christa Martens, Kandis Martin and Mary Mullaney for data collection. Paul Beeson Career Development Award (K23 AG 024812-01, PI Dale) – National Institutes of Aging, American Federation for Aging Research, Student Summer Research (Ahmad, Dale). Pfizer, Inc. (PI Dale, Meltzer) and the Agency for Healthcare Quality and Research through the Hospital Medicine and Economics Center for Education and Research in Therapeutics (CERT) (U18 HS016967-01, PI Meltzer).
Footnotes
Three PSA scores were over three standard deviations away from the median.
When the HADS-A is included in the logistic regression, it does not approach significance (p = 0.62) and does not alter the OR of the MAX-PC predictor. A Link test of the presented model was not significant.
Conflict of interest
The authors have declared that there is no conflict of interest.
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