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American Journal of Men's Health logoLink to American Journal of Men's Health
. 2016 Jul 7;11(1):134–146. doi: 10.1177/1557988315614082

Patient–Provider Communication About Prostate Cancer Screening and Treatment

New Evidence From the Health Information National Trends Survey

Soumitra S Bhuyan 1,✉, Aastha Chandak 2, Niodita Gupta 2, Sudhir Isharwal 2, Chad LaGrange 2, Asos Mahmood 1, Dan Gentry 1
PMCID: PMC5675184  PMID: 26614441

Abstract

The American Urological Association, American Cancer Society, and American College of Physicians recommend that patients and providers make a shared decision with respect to prostate-specific antigen (PSA) testing for prostate cancer (PCa). The goal of this study is to determine the extent of patient–provider communication for PSA testing and treatment of PCa and to examine the patient specific factors associated with this communication. Using recent data from the Health Information National Trends Survey, this study examined the association of patient characteristics with four domains of patient–provider communication regarding PSA test and PCa treatment: (1) expert opinion of PSA test, (2) accuracy of PSA test, (3) side effects of PCa treatment, and (4) treatment need of PCa. The current results suggested low level of communication for PSA testing and treatment of PCa across four domains. Less than 10% of the respondents report having communication about all four domains. Patient characteristics like recent medical check-up, regular healthcare provider, global health status, age group, marital status, race, annual household income, and already having undergone a PSA test are associated with patient–provider communication. There are few discussions about PSA testing and PCa treatment options between healthcare providers and their patients, which limits the shared decision-making process for PCa screening and treatment as recommended by the current best practice guidelines. This study helps identify implications for changes in physician practice to adhere with the PSA screening guidelines.

Keywords: Prostate-specific antigen (PSA) testing, general health and wellness, health communication, healthcare issues, prostate cancer

Introduction

Prostate cancer (PCa) is a growing public health concern in the United States (U.S.) and other developed countries (Quinn & Babb, 2002). According to the Centers for Disease Control and Prevention (2014), PCa is the most common cancer among men in the U.S. In 2014, there were an estimated incidence of 233,000 new cases of PCa and an estimated 29,480 deaths from PCa in the U.S. (Siegel, Ma, Zou, & Jemal, 2014). About 90% of the PCa cases among men in the U.S. are detected through elevated levels of prostate-specific antigen (PSA) in blood during screening for PCa (Siegel et al., 2014).

The effectiveness of PSA screening in reducing PCa specific mortality is highly controversial (Lin, Lipsitz, Miller, & Janakiraman, 2008; Woolf, 1995). Recent randomized clinical trials with longer follow-up time report conflicting evidence. A U.S.-based randomized control trial reported no significant differences in mortality from PCa between the individuals who received PSA screening and those who did not receive screening after 13 years of follow-up (Andriole et al., 2012). Another study conducted in Sweden also revealed no significant differences in the death rate from PCa between those who received screening and those who did not even after 20 years of follow-up (Sandblom, Varenhorst, Rosell, Lofman, & Carlsson, 2011). On the contrary, a randomized control trial conducted in eight European countries observed that PSA screening helped to reduce PCa mortality by about 20% (Schröder et al., 2009).

Additionally, the PSA test used for PCa screening is not specific to PCa and reports false positive results for some benign conditions of prostate gland (Hoffman, 2011). A positive PSA test may encourage the patients to opt for invasive diagnostic procedures such as prostate biopsy (Potosky et al., 2000). If tested positive through a biopsy, men are more likely to undergo immediate treatment such as radical prostatectomies, radiation therapy, and so on that have some important long-term side effects such as urinary incontinence, frequent urination, diarrhea, and decline in sexual function (Potosky et al., 2000; Walter et al., 2013). Diagnosis of an indolent cancer may be monitored with active surveillance which can lead to psychological distress (Mayo Clinic, n.d.). Thus, PSA screening has been noted to increase treatments for PCa patients without improving quality-adjusted life years (Cook & Nelson, 2011; Pataky et al., 2014). Previous studies show evidence that although PSA screening has been proven to increase PCa detection, it may lead to over-diagnosis and over-treatment of PCa that may result in poorer quality of life (Cook & Nelson, 2011; Duffy, 2011; Robinson, Hodges, & Davison, 2014; Schröder et al., 2009).

Based on the available evidence regarding effectiveness of PSA screening, several professional societies in the U.S. have published conflicting recommendations on the use of PSA testing. The U.S. Preventive Services Task Force recommends against the use of PSA testing as a screening and diagnosis tool for men of any age-group (Moyer, 2012). Other professional societies such as the American Urological Association, the American Cancer Society, and the American College of Physicians recommend that the decision to undergo PSA testing should be based on shared decision making between the provider and the patient based on individual’s values and preferences regarding PSA screening (Carter et al., 2013). For example, the American Cancer Society suggests that asymptomatic men who have at least a 10-year life expectancy should discuss with their healthcare provider about the uncertainties, risks, and potential benefits of PSA screening and then make an informed decision (Smith, Cokkinides, & Brawley, 2009; Wolf et al., 2010). The American College of Physicians recommends that clinicians should inform men between the age of 50 and 69 years about the benefits and harms of PSA screening and that the clinicians should not screen for PCa using PSA test in patients who do not express a clear preference for screening (Qaseem, Barry, Denberg, Owens, & Shekelle, 2013). Shared decision making involves providers communicating with the patients to help the patients understand the medical information and collaborate with the patients to make an informed decision in the cases of medical uncertainty (Feng et al., 2013; Hoffman & Helitzer, 2007; Landrey, Matlock, Andrews, Bronsert, & Denberg, 2013).

Previous studies have examined patient–provider communication of the risks and benefits of PSA screening and PCa treatment (Han et al., 2013; Hoffman et al., 2009). In an earlier randomized control trial, men who were provided an informational intervention about the controversial nature of the PSA test reported significantly lower interest in getting the PSA test. This study also noted that men who had a family history of PCa had greater interest while men of advanced age displayed lower interest in the PSA test (Wolf, Nasser, Wolf, & Schorling, 1996). Similarly, another study by Wolf and Schorling (1998) reported that providing elderly (65 years and above) patients with information about PSA testing has been identified to reduce the number of PSA screenings. Chan, Vernon, Haynes, O’Donnell, and Ahn (2003) noted that although physicians recognize the importance of informed decision making, there are differences among physicians in the facts that they consider to be important for the patient to know about PSA test. In a more recent study, Han et al. (2013) examined the prevalence and the extent of shared decision making, PSA screening intensity, and the patient characteristics associated with them (Han et al., 2013). The study noted little shared decision making among patients who received PSA screening and a lack of shared decision making among those patients who did not receive PSA screening and the intensity of screening is highest with partial shared decision making (Han et al., 2013). Although majority of the studies examined patient–provider communication for PSA testing, to the best of our knowledge, no study has examined patient–provider communication about PCa treatment, specifically using nationally representative data. One recent study conducted among European PCa specialists and patients to understand patient-specific opinions and expectations in PCa management reported a large discrepancy between physicians’ and patients’ opinions about the type of provided prognostic and therapeutic information, indicating that patients may not have completely understood this information (Denis, Joniau, Bossi, Baskin-Bey, & Fitzpatrick, 2012).

Given the high number of PCa diagnoses which continue to occur through PSA testing in the U.S. and controversies surrounding the available treatment options for PCa, it becomes essential to understand the current status of communication regarding PSA testing and PCa treatment. Using recent data from the Health Information National Trends Survey (HINTS) database, the objective of this study is to determine the extent of communication between patients and providers about PSA testing and treatment of PCa, as well as to examine the patient-specific factors associated with such communication. The HINTS is a nationally representative survey administered by the National Cancer Institute (NCI, n.d.-a), which focuses on cancer, health communication, and health information environment among the American adult population. To the best of our knowledge, this is the first study to use the HINTS database to examine the patient–provider communication about PSA screening and PCa treatment. Four domains of the patient–provider communication included in this study are (1) expert opinion of PSA test, (2) accuracy of PSA test, (3) side effects of PCa treatment, and (4) treatment need of PCa. The expert opinion of PSA test and the accuracy of PSA test informs about the usefulness of the PSA test, which is currently controversial with respect to its effectiveness. The side effects of PCa treatment and treatment need of PCa informs about the treatment choices for PCa. Since the communication of these four domains inform the patients about the screening and treatment aspects of PCa, they can lead to a shared decision-making process.

Method

Data Sources

This study used data from the HINTS, which is being administered by the National Cancer Institute since 2003 (NCI, n.d.-b). HINTS is a national sample of civilian non-institutionalized adults in the U.S. aged 18 years or older. This study uses the fourth edition of this survey known as HINTS 4, which was conducted using a self-administered mailed questionnaire (NCI, n.d.-a). The HINTS 4 includes five data collection cycles over a course of 3 years. For the purpose of this study, the sample was obtained from the two recent cycles of HINTS 4: Cycle 2 and Cycle 3. Cycle 2 was fielded from October 2012 to January 2013 and consisted of 3,630 respondents, and Cycle 3 was fielded from September to November 2013 and consisted of 3,185 respondents. The dependent variables for this study, which represent the four domains of communication of PSA testing and PCa treatment among men, did not vary between Cycle 2 and Cycle 3. Hence, data from the two cycles were aggregated.

Inclusion Criteria

The final study sample consists of males without any prior history of cancer and ages 40 years or older. The final sample size used in this study was 1,706. Furthermore, only those respondents who had valid responses for the each individual domain of communication regarding PSA testing were used in the analysis for that domain of communication. Hence, the analytic sample for each domain of communication varies.

Measures

Dependent Variables

The key dependent variables in this study were the four domains of communication between provider and patient with regard to PSA tests and PCa treatment. These domains were categorized as communication regarding (1) expert opinion of PSA test, (2) accuracy of PSA test, (3) side effects of PCa treatment, and (4) treatment need of PCa. Communication regarding expert opinion of PSA test was defined as: whether a doctor told the patient that some experts disagree about whether men should have PSA tests. Communication regarding accuracy of PSA test was defined as: whether a doctor or other healthcare professional ever told the patient that the PSA test is not always accurate for diagnosis of PCa. Communication regarding side effects of PCa treatment was defined as: whether a doctor or healthcare professional ever told the patient that treating any type of PCa can lead to serious side effects, such as urinary incontinence or erectile dysfunction. Communication regarding treatment need of PCa was defined as: whether a doctor or other healthcare professional ever told the patient that some types of PCa are slow growing and need no treatment.

Independent Variables

The key independent variables included in this study were grouped under access to care, patient characteristics, and individual perception about cancer risk. Factors related to access to care include having a regular provider, having a recent regular check-up, and availability of health insurance. Previous studies have identified evidence that patients with a regular provider are more likely to use preventative services such as screening (Carpenter et al., 2009). Furthermore, usual source of medical care and availability of health insurance has been previously determined as factors associated with PSA test use, and thus, these factors could have an impact on the communication about PSA testing and PCa screening (Eisen et al., 1999; Ettner, 1999; Han, Coates, Uhler, & Breen, 2006; Han et al., 2013). Patient factors include age, marital status, education level, ethnicity, race, annual household income, geographic location of residence, and health status. Previous studies have reported all these patient characteristics to be associated with PSA testing use (Close, Kristal, Li, Patterson, & White, 1998; Eisen et al., 1999; Etzioni, Berry, Legler, & Shaw, 2002; Han et al., 2006; Han et al., 2013; Sirovich, Schwartz, & Woloshin, 2003). Furthermore, the individual perception of cancer risk included the patient’s perception about their likelihood of getting cancer and a previous family history of cancer. These factors have been reported to play a role in self-referral of the patients to get screened (Taylor et al., 1999).

Having a regular provider was categorized as whether or not the respondent had a regular provider to seek care from. Most recent regular check-up was categorized (1) less than 12 months ago, (2) 1- to 2 years ago, (3) 2- to 5 years ago, and (4) 5 years ago or never had a regular check-up. Availability of health insurance was categorized as whether or not the respondent had any kind of health insurance coverage. Demographic characteristics were represented by age, marital status, education, race, and ethnicity. Age was categorized as (1) 40 to 49 years, (2) 50 to 64 years, and (3) older than 65 years. Marital status was represented by (1) respondent was married and (2) respondent was not married (single, separated, divorced, and widowed). Education was categorized as (1) less than high school, (2) high school graduate, (3) some college, and (4) college graduate or more. Race was categorized as (1) White, (2) African American, and (3) other races. Ethnicity was categorized as whether the respondent was of Hispanic ethnicity or not. Socioeconomic status was represented by the annual household income categorized as (1) less than $20,000, (2) between $20,000 and $34,999, (3) between $35,000 and $49,999, (4) between $50,000 and $74,999, and (5) $75,000 or more. Previous history of cancer in family was categorized as (1) yes, (2) no, and (3) not sure. Global health rating was obtained from the self-reported health status and was categorized as (1) poor or fair, (2) good, and (3) excellent or very good. Perception about getting cancer was obtained from the self-reported likelihood of getting cancer and was categorized as (1) very unlikely or unlikely, (2) neither unlikely nor likely, and (4) likely or very likely. Geographic location of residence was assessed by the rural and urban location of residence as defined by the Rural-Urban Commuting Area Codes (WWAMI RUCA Rural Health Research Center, n.d.).

Statistical Analysis

The unit of analysis is the individual who responded to the survey. Descriptive statistics were used to assess the weighted proportion of the communication of the four domains of interest, and the weighted percentage of each independent variable among those who communicated about each of the four domains. In the HINTS database, weighting is done using the Jackknife replicate weights. Multivariate logistic regression using the jackknife replicates was used to assess the relationship between the independent variables and the four domains of communication. Specifically, Model 1 analyzes communication about expert opinion of PSA test, Model 2 analyzes communication about accuracy of PSA test, Model 3 analyzes communication about side effects of PCa treatment and Model 4 analyzes communication about the treatment need of PCa. All statistical analyses were conducted using SAS version 9.4 (SAS Institute Inc.).

Results

Table 1 describes the characteristics of all respondents in the study sample along with the weighted percentages. It also describes the characteristics of respondents and weighted percentages for those who received communication about each of the four domains of interest. There was a relatively lower proportion of patients who received communication of the four domains from their healthcare providers. Among the total patients (N = 1,706) who were 40 years of age or older and did not suffer from cancer, doctors communicated with about 17% that some experts disagree about whether men should have PSA tests, healthcare providers told 25% that PSA test is not always accurate, healthcare providers mentioned to about 31% that treating any type of PCa can lead to serious side effects, such as urinary incontinence and erectile dysfunction, and informed about 23% that some types of PCa are slow-growing and need no treatment. Only 9.2% received communication about all four domains. A majority of the patients who received communication about any of the four domains had a regular provider, had their most recent regular check-up within the last 12 months and had health insurance. The majority were of 50 years of age or older and were married and lived in an urban area. Among those patients who had received the communication about any of the four domains, a higher proportion underwent PSA testing as compared to all the patients in the sample.

Table 1.

Descriptive Statistics of All Respondents and Those Respondents That Received Positive Communication in the Four Domains.

All respondents (N = 1,706)
 Did a doctor ever tell you that some experts disagree about whether men should have PSA tests? (N = 1,644)
 Has a doctor or other healthcare professional ever told you that the PSA test is not always accurate? (N = 1,624)
 Has a doctor or other healthcare professional ever told you that treating any type of prostate cancer can lead to serious side effects, such as problems with urination or having sex? (N = 1,610)
 Has a doctor or other healthcare professional ever told you that some types of prostate cancer are slow-growing and need no treatment? (N = 1,611)
Sample N Weighted % Sample N Weighted % Sample N Weighted % Sample N Weighted % Sample N Weighted %
Domain communication — — 315 17.23 441 25.40 540 30.69 414 23.26
Regular provider
 Yes 1,145 66.99 238 78.98 344 80.31 411 80.30 319 82.76
 No 523 33.01 68 21.02 91 19.69 117 19.70 89 17.24
Most recent check-up
 <12 months 1,198 66.82 251 78.44 342 74.94 413 74.21 327 79.95
 1-2 years 217 14.49 33 14.42 49 15.83 59 16.13 42 11.08
 3-5 years 117 8.14 17 5.52 27 6.27 32 5.59 21 5.82
 >5 years or never 149 10.54 11 1.62 19 2.96 26 4.07 21 3.15
Health insurance coverage
 Yes 1,490 85.99 283 91.25 405 91.69 492 91.39 384 94.24
 No 199 14.01 29 8.75 32 8.31 40 8.61 27 5.76
Age group (years)
 40-49 402 37.13 31 18.71 44 17.01 59 18.99 40 15.08
 50-64 802 42.09 148 48.72 214 51.22 261 49.33 190 50.77
 ≥65 502 20.78 136 32.57 183 31.77 220 31.67 184 34.15
Married
 Yes 965 64.73 201 77.01 276 72.76 325 69.33 251 72.31
 No 717 35.27 106 22.99 160 27.24 205 30.67 156 27.69
Education level
 Less than high school 185 11.82 24 10.00 26 6.96 53 10.88 32 9.28
 High school graduate 383 23.83 53 19.15 76 17.47 102 18.87 67 16.33
 Some college 504 32.92 79 26.73 108 29.17 147 31.08 102 27.93
 College graduate or more 624 31.43 159 44.12 229 46.40 235 39.17 210 46.46
Hispanic ethnicity
 Yes 256 12.93 38 12.49 44 8.96 74 12.00 50 10.36
 No 1,305 87.07 248 87.51 370 91.04 429 88.00 335 89.64
Race
 White 1,247 82.51 252 85.03 366 87.72 410 81.50 335 84.49
 African American 226 9.39 30 8.81 40 7.27 67 10.48 34 8.82
 Other 140 8.10 20 6.16 24 5.01 39 8.02 24 6.68
Annual household income ($)
 <20,000 340 16.40 44 9.22 57 9.92 87 12.95 50 8.22
20,000-34,999 256 14.20 34 11.42 58 11.95 71 12.20 54 11.39
 35,000-49,999 222 12.45 37 11.51 48 8.77 67 11.26 55 13.57
 50,000-74,999 277 18.22 56 18.48 87 19.68 106 22.01 71 17.11
 ≥75,000 572 38.73 138 49.37 185 49.67 195 41.58 173 49.72
Family member ever had cancer
 Yes 1,013 60.06 206 63.14 280 61.09 336 61.94 254 60.86
 No 532 31.80 88 30.39 131 33.38 170 34.00 135 34.56
 Not sure 127 8.14 16 6.47 22 5.53 26 4.06 18 4.57
Global health status
 Excellent or very good 768 44.37 163 51.93 235 53.83 276 52.42 221 55.39
 Good 625 40.26 111 36.18 150 35.96 177 35.08 135 34.96
 Fair or poor 271 15.37 32 11.89 44 10.21 70 12.50 41 9.65
Perception about chance of getting cancer
 Very unlikely or unlikely 381 21.85 58 18.70 81 18.81 108 20.89 90 25.05
 Neither unlikely nor likely 738 44.12 144 45.84 202 44.63 247 45.53 183 41.90
 Likely or very likely 521 34.03 101 35.46 147 36.56 171 33.58 129 33.05
Location of residence
 Urban 1,436 82.27 272 84.55 374 83.87 453 84.90 350 85.23
 Rural 270 17.73 43 15.45 67 16.13 87 15.10 64 14.77
Ever had PSA test?
 Yes 912 49.14 268 84.78 382 85.10 432 80.33 340 83.39
 No 752 50.86 46 15.22 57 14.90 101 19.67 68 16.61
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Note. PSA = prostate-specific antigen.

The results of the multivariate logistic regression of the likelihood of communication between the provider and the patient about expert opinion and accuracy of PSA tesint and side effects and need of PCa treatment are summarized in Table 2. Having a PSA test was significantly associated with all four communication domains. In addition, some patient characteristics were significantly associated with each communication domains separately as noted below.

Table 2.

Multivariate Logistic Regression Models for Association between Patient Characteristics and Positive Patient–Provider Communication about Prostate Cancer Screening and Treatment.

Model 1
 Model 1
 Model 3
 Model 4
Did a doctor ever tell you that some experts disagree about whether men should have PSA tests? Has a doctor or other healthcare professional ever told you that the PSA test is not always accurate? Has a doctor or other healthcare professional ever told you that treating any type of prostate cancer can lead to serious side effects, such as problems with urination or having sex? Has a doctor or other healthcare professional ever told you that some types of prostate cancer are slow-growing and need no treatment?
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Regular provider
 No — — — — — — — —
 Yes 1.444 [0.754, 2.767] 1.415 [0.748, 2.677] 1.745* [1.032, 2.948] 1.487 [0.833, 2.652]
Most recent check-up
 >5 years or never — — — — — — — —
 <12 months 7.569** [1.975, 29.001] 3.084 [0.764, 12.453] 1.366 [0.425, 4.393] 1.980 [0.490, 7.995]
 1-2 years 9.694** [2.238, 41.983] 6.108* [1.486, 25.106] 2.158 [0.555, 8.382] 1.855 [0.485, 7.100]
 3-5 years 6.423* [1.317, 31.334] 3.669 [0.946, 14.229] 1.297 [0.366, 4.595] 2.329 [0.559, 9.709]
Health insurance coverage
 No — — — — — — — —
 Yes 0.370 [0.118, 1.157] 0.649 [0.248, 1.703] 0.949 [0.384, 2.346] 1.162 [0.247, 5.457]
Age-group (years)
 40-49 — — — — — — — —
 50-64 1.456 [0.538, 3.944] 1.987 [0.870, 4.538] 1.992* [1.063, 3.736] 2.366* [1.160, 4.827]
 >65 2.136 [0.643, 7.101] 2.809* [1.093, 7.215] 2.703** [1.284, 5.688] 3.567** [1.572, 8.095]
Married
 No — — — — — — — —
 Yes 1.781* [1.134, 2.798] 1.146 [0.777, 1.689] 0.953 [0.600, 1.514] 0.964 [0.635, 1.464]
Education Level
 Less than high school — — — — — — — —
 High school graduate 0.818 [0.165, 4.052] 1.015 [0.299, 3.442] 0.464 [0.177, 1.218] 0.771 [0.175, 3.392]
 Some college 0.905 [0.174, 4.703] 1.239 [0.367, 4.185] 0.591 [0.222, 1.578] 1.064 [0.283, 4.002]
 College graduate or more 1.216 [0.274, 5.384] 1.903 [0.617, 5.872] 0.562 [0.214, 1.48] 1.402 [0.365, 5.381]
Hispanic ethnicity
 No — — — — — — — —
 Yes 1.397 [0.589, 3.310] 0.766 [0.349, 1.683] 1.145 [0.480, 2.729] 1.249 [0.553, 2.823]
Race
 White — — — — — — — —
 African American 1.012 [0.257, 3.992] 0.917 [0.321, 2.622] 1.451 [0.739, 2.847] 1.099 [0.423, 2.858]
 Other 1.164 [0.355, 3.817] 0.934 [0.353, 2.473] 2.646* [1.100, 6.368] 1.827 [0.753, 4.435]
Annual household income ($)
 <20,000 — — — — — — — —
 20,000-34,999 1.971 [0.649, 5.978] 1.115 [0.430, 2.889] 0.74 [0.356, 1.539] 2.026 [0.686, 5.979]
 35,000-49,999 2.508 [0.934, 6.733] 0.865 [0.352, 2.124] 0.942 [0.483, 1.838] 3.046** [1.362, 6.813]
 50,000-74,999 2.195 [0.908, 5.31] 1.325 [0.580, 3.027] 1.724 [0.716, 4.147] 2.275 [0.948, 5.457]
 ≥75,000 2.438 [0.946, 6.287] 1.309 [0.547, 3.131] 0.844 [0.400, 1.781] 2.364 [0.919, 6.081]
Family member ever had cancer
 No — — — — — — — —
 Yes 1.216 [0.680, 2.175] 1.365 [0.865, 2.156] 1.321 [0.850, 2.053] 1.544 [0.928, 2.57]
 Not sure 1.223 [0.469, 3.187] 0.980 [0.416, 2.311] 0.472 [0.214, 1.043] 0.652 [0.265, 1.601]
Global health status
 Excellent or very good — — — — — — — —
 Good 0.917 [0.589, 1.430] 0.786 [0.482, 1.280] 0.606* [0.392, 0.937] 0.625* [0.418, 0.935]
 Poor or fair 0.927 [0.337, 2.556] 0.753 [0.351, 1.613] 0.666 [0.340, 1.308] 0.660 [0.284, 1.534]
Perception about chance of getting cancer
 Very likely or unlikely — — — — — — — —
 Neither unlikely nor likely 1.538 [0.833, 2.840] 1.145 [0.763, 1.718] 1.154 [0.804, 1.658] 0.864 [0.503, 1.484]
 Likely or very likely 1.554 [0.741, 3.263] 1.347 [0.767, 2.366] 1.167 [0.712, 1.912] 1.010 [0.511, 1.995]
Location of residence
 Urban — — — — — — — —
 Rural 0.979 [0.523, 1.833] 1.078 [0.664, 1.752] 0.841 [0.486, 1.452] 0.952 [0.536, 1.688]
Ever had PSA test?
 No — — — — — — — —
 Yes 5.412*** [2.504, 11.697] 6.787*** [3.658, 12.592] 6.199*** [3.437, 11.183] 5.867*** [3.373, 10.205]
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Note. PSA = prostate-specific antigen; OR = odds ratio. Exponentiated coefficients, 95% confidence intervals (CI) in brackets.

*

p < .05. **p < .01. ***p < .001.

Model 1

Model 1 analyzes the patient–provider communication about whether a doctor told the patient that some experts disagree about the effectiveness of the PSA test. The results from Model 1 suggest that patients who had their last regular check-up within the past 12 months (odds ratio [OR] = 7.569; 95% confidence interval [CI] = [1.975, 29.001]), between 1 and 2 years (OR = 9.694; 95% CI = [2.238, 41.983]), and between 3 and 5 years (OR = 6.423; 95% CI = [1.317, 31.334]) were more likely to receive communication from a doctor about expert opinion of PSA test as compared to those who had their last regular check-up more than 5 years ago or never had a regular checkup. Those who were married were 1.8 times more likely (OR = 1.781; 95% CI = [1.134, 2.798]) to receive communication from a doctor about expert opinion of PSA test.

Model 2

Model 2 analyzes the patient–provider communication about whether a doctor or other healthcare professional informed the patient that PSA tests are not always accurate. As evident from the results in Model 2, patients who had their last regular check-up between 1 and 2 years were 6.1 times more likely (OR = 6.108; 95% CI = [1.486, 25.106]) to receive communication from a doctor or other healthcare professional about accuracy of PSA test as compared to those who had their last regular check-up more than 5 years ago or never had a regular check-up. Those aged 65 years or older were 2.8 times more likely (OR = 2.809; 95% CI = [1.093, 7.215]) to receive communication from a doctor or other healthcare professional about accuracy of the PSA test as compared to those who were 40 to 49 years of age.

Model 3

Model 3 analyzes patient–provider communication about whether a doctor or other healthcare professional informed the patient that treating any type of PCa can lead to serious side effects, such as problems with urination or having sex. The results from Model 3 exhibit that the patients who had a regular provider were 1.7 times more likely (OR = 1.745; 95% CI = [1.032, 2.948]) to receive communication from a doctor or other healthcare professional about the side effects of PCa treatment. Patients who were aged 50 to 64 years (OR = 1.992; 95% CI = [1.063, 3.736]), and those aged 65 years or older were more likely (OR = 2.703; 95% CI = [1.284, 5.688]) to receive communication from a doctor or other healthcare professional about the side effects of PCa treatment as compared with those who were 40 to 49 years of age.

Model 4

Model 4 analyzes the patient–provider communication about whether a doctor or other healthcare professional informed the patient that some types of PCa are slow-growing and need no treatment. Older people are more likely to receive communication about slow growing nature of PCa. Results from Model 4 show that patients who were aged 50 to 64 years were 2.4 times more likely (OR = 2.366; 95% CI = [1.160, 4.827]), and those aged 65 years or more were 3.6 times more likely (OR = 3.567; 95% CI = [1.572, 8.095]) to receive communication from a doctor or other healthcare professional about treatment need of PCa as compared to those who were aged 40 to 49 years. Financial status of a patient also impacts the communication between him and the doctor or other healthcare professional. Those whose annual household income was between $35,000 and $49,999 were 3.05 times more likely (OR = 3.046; 95% CI = [1.362, 6.813]) to receive communication from a doctor or other healthcare professional about the treatment need of PCa as compared with those whose annual household income was less than $20,000.

The control variable of ever having a PSA test before was positively associated with the communication of each of the four domains considered. Those patients who had a PSA test were 5.4 times more likely (OR = 5.412; 95% CI = [2.504, 11.697]) to receive communication from a doctor about the expert opinion of PSA test, were 6.8 times more likely (OR = 6.787; 95% CI = [3.658, 12.592]) to receive communication from a doctor or other healthcare professional about accuracy of the PSA test, were 6.2 times more likely (OR = 6.199; 95% CI = [3.437, 11.183]) to receive communication from a doctor or other healthcare professional about the side effects of PCa treatment and were 5.9 times more likely (OR = 5.867; 95% CI = [3.373, 10.205]) to receive communication from a doctor or other healthcare professional about the treatment need for PCa.

Furthermore, the patients who had a regular provider were 2.54 times more likely (OR = 2.540; 95% CI = [1.081, 5.969]) to receive communication in all four domains. Those whose annual household income was between $35,000 and $49,999 were 3.67 times more likely (OR = 3.665; 95% CI = [1.223, 10.988]), those whose annual household income was between $50,000 and $74,999 were 3.62 times more likely (OR = 3.623; 95% CI = [1.244, 10.552]), and those whose annual household income was $75,000 or more were 3.49 times more likely (OR = 3.492; 95% CI = [1.165, 10.469]) to receive communication in all four domains as compared to those whose annual household income was less than $20,000.

Discussion

This study examined the communication between patients and providers, which is required for shared decision making for PSA testing and PCa treatment options. Using the HINTS, the extent of information sharing about effectiveness of PSA test and treatment for PCa patients by the healthcare providers toward their patients was examined. The association between patient characteristics and communication between the patients and providers was also assessed. Healthcare providers communicated with the patients about controversies around PSA screening in 17.2% of the times, accuracy of the PSA screening in 25.4% of the times, side effects of PCa treatment in 30.7% of the times, and slow-growing cancer with option of surveillance in only 23.3% of the times. A recent medical check-up, availability of regular healthcare provider, overall health status, age group, marital status, race, annual household income, and already having undergone a PSA test were associated with patient–provider communication. Some of the results of this study are consistent with previously conducted research on patient level determinants of receiving PSA screening and provider–patient communication regarding PSA screening (Close et al., 1998; Eisen et al., 1999; Han et al., 2013; Merrill, 2001; Rutten, Meissner, Breen, Vernon, & Rimer, 2005; Steele, Miller, Maylahn, Uhler, & Baker, 2000). Several studies that examined the factors associated with obtaining a PSA screening reported that subjects with regular care and a healthcare physician and those having health insurance, higher education, and better health status had higher rates of obtaining a PSA screening (Close et al., 1998; Eisen et al., 1999; Merrill, 2001; Rutten et al., 2005).

It is interesting to note that in less than 30% of the times, the provider informed the patient about accuracy of PSA screening and risks and benefits of PCa treatment and treatment options. Although the recommendations of several professional associations and available literature emphasize on patient–provider communication and shared decision making (Austin, 2012; Carter et al., 2013; Duffy, 2011; Flood et al., 1996; Gomella et al., 2011; Hoffman et al., 2009; McCormick, Osman, & Pomerantz, 2010; Moyer, 2012; Noguez & Fantz, 2014), the current study observes low level of communication between the patients and the providers about PSA screening and PCa treatment. Previous literature has noted physician characteristics like physician belief about PSA screening, medico-legal risks for the physician, physician forgetfulness, and patient characteristics like patient comorbidity, health literacy, education, and prior refusal of care as significant barriers to the patient–provider communication and shared decision making (Guerra, Jacobs, Holmes, & Shea, 2007; Volk et al., 2013).

With the implementation of Affordable Care Act, hospitals and physician offices are receiving incentives to adopt electronic health record system (Patient Protection and Affordable Care Act of 2010). One component of the electronic health record system is clinical decision support tool with best practice guidelines for the healthcare providers (Kocher, Emanuel, & DeParle, 2010); this decision support system may help remind the physicians about informing the patients about PSA screening and treatment options for PCa, thus help promote shared decision making (Kocher et al., 2010).

It is possible that patients who have recently had a medical check-up have increased awareness about preventive services, access to preventive services, and may initiate conversations with the provider. The proactive behavior on part of the patient may have lead the provider to inform the patient about the possible risks and benefits (Mukherjee & Segal, 2015; Rutten et al., 2005). Having a regular healthcare provider may help to develop a trusting patient–provider relationship, which may motivate the provider to be more involved in their patients’ healthcare (Murray, Pollack, White, & Lo, 2007) The patient–provider relationship may prompt the providers to communicate about PSA screening (Murray et al., 2007). Previous literature has also noted that the patients receive more preventive services when the patients have a regular provider (Ettner, 1999).

Elderly patients may be more aware of common chronic conditions affecting people in their age group. Their social network may have a higher percentage of men who have had a PSA test, which may encourage them to seek information from their healthcare providers (Forbat et al., 2013). Older patients were more likely to present with an advanced stage disease, which increases the likelihood of death (Scosyrev, Messing, Mohile, Golijanin, & Wu, 2011). Older patients are more risk averse as compared to the younger patients (Mukherjee & Segal, 2015). This may prompt the physicians to provide information about PSA screening to their older patients. It may be reasonable to assume that younger patients have more years to live, which might bias the physician’s decision toward administering the PSA screening test. Although PCa is slow growing in nature, physicians may assume that the PCa may progress to advanced stage, causing untimely death of their younger PCa patient. Medico-legal risk associated with not administering PSA test, which may or may not have prolonged the life of a young patient, may also motivate the doctors to screen the younger patients (Volk et al., 2013). Better family support may have been a motivating factor to the married persons to inquire about preventive services such as PSA screening (Shaw, Scott, & Ferrante, 2013). Higher annual household income could suggest affordability of healthcare services, either via insurance or out-of-pocket payments, which may lead to increased use of preventive services among this population subgroup. Lack of shared decision making is likely to generate doubt about physician’s intent. Overdiagnosis and overtreatment as a result of PSA testing is well documented; it is plausible that over-diagnosis and over-treatments induces a demand for biopsies and surgeries such as robot-assisted surgeries, which benefits the physicians financially (Cook & Nelson, 2011; Duffy, 2011; Robinson et al., 2014).

The current study has few limitations. First, cross-sectional data were used; hence no inference about causality can be made with respect to the study results. Second, the data used in this study were self-reported information, which might have recall bias. The patients may or may not recall and report their conversations with the providers. Third, other barriers like physician visit time and patient knowledge about PSA testing as well as the physician perception about PSA testing that may have affected the patient–provider communication were not included because of lack of data availability. The patients who have undergone PSA test in the past are more likely to have discussion with their providers about PSA screening; this variable was used as a control factor to account for those patients who have had received communication as a part of their PSA screening. However, it cannot be concluded whether the communication was before or after the PSA screening. These data have limited information on the type of physician visit. It is possible that conversations and discussions about screening and preventive services are more common during annual check-ups, however, this aspect could not be assessed due to the nature of the survey data. Furthermore, the models in this study were designed according to the questions asked in the HINTS. In the first model, the question specifically mentioned if “a doctor” informed the patient about expert opinion on PSA testing; however, in the other three models, the question asked if “a doctor or other healthcare professionals” provided information to the patients. It may be possible that some patients may have been counseled by healthcare professionals other than doctors that may not be accounted for in the first model and may lead to some bias.

Conclusions

Based on the results of this study, it can be concluded that there are few discussions about PSA testing and PCa treatment between healthcare providers and their patients, which limits the shared decision-making process for PCa screening as recommended by the guidelines. Age of patient, financial status, regular primary care provider, recent medical check-up, global health status, and marital status are significantly associated with provider–patient communication. This study helps identify implications for changes in physician practice to adhere with the PSA screening guidelines. Physicians could be more mindful about providing information to all their patients about PSA screening and PCa treatment and facilitate shared decision making.

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

  1. Andriole G. L., Crawford E. D., Grubb R. L., Buys S. S., Chia D., Church T. R., . . . Prorok P. C. (2012). Prostate cancer screening in the randomized prostate, lung, colorectal, and ovarian cancer screening trial: Mortality results after 13 years of follow-up. Journal of the National Cancer Institute, 104, 125-132. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Austin O. J. (2012). Prostate-specific antigen prostate cancer screening: Answers to the critical questions. Annals of Long Term Care, 20, 16-21. [Google Scholar]
  3. Carpenter W. R., Godley P. A., Clark J. A., Talcott J. A., Finnegan T., Mishel M., . . . Mohler J. L. (2009). Racial differences in trust and regular source of patient care and the implications for prostate cancer screening use. Cancer, 115, 5048-5059. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Carter H. B., Albertsen P. C., Barry M. J., Etzioni R., Freedland S. J., Greene K. L., . . . Zietman A. L. (2013). Early detection of prostate cancer: AUA guideline. Journal of Urology, 190, 419-426. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Centers for Disease Control and Prevention. (2014). Prostate cancer. Retrieved from http://www.cdc.gov/cancer/prostate/
  6. Chan E. C., Vernon S. W., Haynes M. C., O’Donnell F. T., Ahn C. (2003). Physician perspectives on the importance of facts men ought to know about prostate-specific antigen testing. Journal of General Internal Medicine, 18, 350-356. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Close D. R., Kristal A. R., Li S., Patterson R. E., White E. (1998). Associations of demographic and health-related characteristics with prostate cancer screening in Washington state. Cancer Epidemiology Biomarkers & Prevention, 7, 627-630. [PubMed] [Google Scholar]
  8. Cook E. D., Nelson A. C. (2011). Prostate cancer screening. Current Oncology Reports, 13(1), 57-62. [DOI] [PubMed] [Google Scholar]
  9. Denis L., Joniau S., Bossi A., Baskin-Bey E., Fitzpatrick J. M. (2012). PCA: Prostate cancer, patient-centred approach or both? BJU International, 110, 16-22. [DOI] [PubMed] [Google Scholar]
  10. Duffy M. J. (2011). Prostate-specific antigen: Does the current evidence support its use in prostate cancer screening? Annals of Clinical Biochemistry, 48, 310-316. [DOI] [PubMed] [Google Scholar]
  11. Eisen S. A., Waterman B., Skinner C. S., Scherrer J. F., Romeis J. C., Bucholz K., . . . True W. R. (1999). Sociodemographic and health status characteristics associated with prostate cancer screening in a national cohort of middle-aged male veterans. Urology, 53, 516-522. [DOI] [PubMed] [Google Scholar]
  12. Ettner S. L. (1999). The relationship between continuity of care and the health behaviors of patients: Does having a usual physician make a difference? Medical Care, 37, 547-555. [DOI] [PubMed] [Google Scholar]
  13. Etzioni R., Berry K. M., Legler J. M., Shaw P. (2002). Prostate-specific antigen testing in black and white men: An analysis of Medicare claims from 1991–1998. Urology, 59, 251-255. [DOI] [PubMed] [Google Scholar]
  14. Feng B., Srinivasan M., Hoffman J. R., Rainwater J. A., Griffin E., Dragojevic M., . . . Wilkes M. S. (2013). Physician communication regarding prostate cancer screening: Analysis of unannounced standardized patient visits. Annals of Family Medicine, 11, 315-323. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Flood A. B., Wennberg J. E., Nease R. F., Jr., Fowler F. J., Jr., Ding J., Hynes L. M. Prostate Patient Outcomes Research Team. (1996). The importance of patient preference in the decision to screen for prostate cancer. Journal of General Internal Medicine, 11, 342-349. [DOI] [PubMed] [Google Scholar]
  16. Forbat L., Place M., Kelly D., Hubbard G., Boyd K., Howie K., Leung H. Y. (2013). A cohort study reporting clinical risk factors and individual risk perceptions of prostate cancer: Implications for PSA testing. BJU International, 111, 389-395. [DOI] [PubMed] [Google Scholar]
  17. Gomella L. G., Liu X. S., Trabulsi E. J., Kelly W. K., Myers R., Showalter T., . . . Wender R. (2011). Screening for prostate cancer: The current evidence and guidelines controversy. Canadian Journal of Urology, 18, 5875-5883. [PubMed] [Google Scholar]
  18. Guerra C. E., Jacobs S. E., Holmes J. H., Shea J. A. (2007). Are physicians discussing prostate cancer screening with their patients and why or why not? A pilot study. Journal of General Internal Medicine, 22, 901-907. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Han P. K., Coates R. J., Uhler R. J., Breen N. (2006). Decision making in prostate-specific antigen screening: National Health Interview Survey, 2000. American Journal of Preventive Medicine, 30, 394-404. [DOI] [PubMed] [Google Scholar]
  20. Han P. K., Kobrin S., Breen N., Joseph D. A., Li J., Frosch D. L., Klabunde C. N. (2013). National evidence on the use of shared decision making in prostate-specific antigen screening. Annals of Family Medicine, 11, 306-314. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hoffman R. M. (2011). Screening for prostate cancer. New England Journal of Medicine, 365, 2013-2019. [DOI] [PubMed] [Google Scholar]
  22. Hoffman R. M., Couper M. P., Zikmund-Fisher B. J., Levin C. A., McNaughton-Collins M., Helitzer D. L., . . . Barry M. J. (2009). Prostate cancer screening decisions: Results from the National Survey of Medical Decisions (DECISIONS study). Archives of Internal Medicine, 169, 1611-1618. [DOI] [PubMed] [Google Scholar]
  23. Hoffman R. M., Helitzer D. L. (2007). Moving towards shared decision making in prostate cancer screening. Journal of General Internal Medicine, 22, 1056-1057. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Kocher R., Emanuel E. J., DeParle N. A. M. (2010). The Affordable Care Act and the future of clinical medicine: The opportunities and challenges. Annals of Internal Medicine, 153, 536-539. [DOI] [PubMed] [Google Scholar]
  25. Landrey A. R., Matlock D. D., Andrews L., Bronsert M., Denberg T. (2013). Shared decision making in prostate-specific antigen testing the effect of a mailed patient flyer prior to an annual exam. Journal of Primary Care & Community Health, 4, 67-74. [DOI] [PubMed] [Google Scholar]
  26. Lin K., Lipsitz R., Miller T., Janakiraman S. (2008). Benefits and harms of prostate-specific antigen screening for prostate cancer: An evidence update for the US Preventive Services Task Force. Annals of Internal Medicine, 149, 192-199. [DOI] [PubMed] [Google Scholar]
  27. Mayo Clinic. (n.d.). Tests and procedures: PSA test. Retrieved from http://www.mayoclinic.org/tests-procedures/psa-test/basics/risks/prc-20013324
  28. McCormick K. A., Osman N. Y., Pomerantz M. M. (2010). Update on prostate cancer screening. Journal of Clinical Outcomes Management, 17, 470-479. [Google Scholar]
  29. Merrill R. M. (2001). Demographics and health-related factors of men receiving prostate-specific antigen screening in Utah. Preventive Medicine, 33, 646-652. [DOI] [PubMed] [Google Scholar]
  30. Moyer V. A. (2012). Screening for prostate cancer: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 157, 120-134. [DOI] [PubMed] [Google Scholar]
  31. Mukherjee K., Segal R. (2015). Discussions with healthcare providers about prostate-specific antigen testing: Evidence from the Behavioral Risk Factor Surveillance System in the USA. Journal of Pharmaceutical Health Services Research, 6(1), 47-52. [Google Scholar]
  32. Murray E., Pollack L., White M., Lo B. (2007). Clinical decision-making: Patients’ preferences and experiences. Patient Education and Counseling, 65, 189-196. [DOI] [PubMed] [Google Scholar]
  33. National Cancer Institute. (n.d.-a). Frequently asked questions about HINTS. Retrieved from http://hints.cancer.gov/faq.aspx
  34. National Cancer Institute. (n.d.-b). Health Information National Trends Survey 4 (HINTS 4). Retrieved from http://hints.cancer.gov/
  35. Noguez J. H., Fantz C. R. (2014). Pathology consultation on prostate-specific antigen testing. American Journal of Clinical Pathology, 142, 7-15. [DOI] [PubMed] [Google Scholar]
  36. Pataky R., Gulati R., Etzioni R., Black P., Chi K. N., Coldman A. J., . . . Peacock S. (2014). Is prostate cancer screening cost-effective? A microsimulation model of prostate-specific antigen-based screening for British Columbia, Canada. International Journal of Cancer, 135, 939-947. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010). [Google Scholar]
  38. Potosky A. L., Legler J., Albertsen P. C., Stanford J. L., Gilliland F. D., Hamilton A. S., . . . Harlan L. C. (2000). Health outcomes after prostatectomy or radiotherapy for prostate cancer: Results from the prostate cancer outcomes study. Journal of the National Cancer Institute, 92, 1582-1592. [DOI] [PubMed] [Google Scholar]
  39. Qaseem A., Barry M. J., Denberg T. D., Owens D. K., Shekelle P. (2013). Screening for prostate cancer: A guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine, 158, 761-769. [DOI] [PubMed] [Google Scholar]
  40. Quinn M., Babb P. (2002). Patterns and trends in prostate cancer incidence, survival, prevalence and mortality: Part I. International comparisons. BJU International, 90, 162-173. [DOI] [PubMed] [Google Scholar]
  41. Robinson J. G., Hodges E., Davison J. (2014). Prostate-specific antigen screening: A critical review of current research and guidelines. Journal of the American Association of Nurse Practitioners, 26, 574-581. [DOI] [PubMed] [Google Scholar]
  42. Rutten L. J. F., Meissner H. I., Breen N., Vernon S. W., Rimer B. K. (2005). Factors associated with men’s use of prostate-specific antigen screening: Evidence from Health Information National Trends Survey. Preventive Medicine, 40, 461-468. [DOI] [PubMed] [Google Scholar]
  43. Sandblom G., Varenhorst E., Rosell J., Löfman O., Carlsson P. (2011). Randomised prostate cancer screening trial: 20 year follow-up. BMJ, 342, d1539. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. SAS Institute. (SAS Version 9.4) [Computer software]. Cary, NC. [Google Scholar]
  45. Schröder F. H., Hugosson J., Roobol M. J., Tammela T. L., Ciatto S., Nelen V., . . . Auvinen A. ERSPC Investigators. (2009). Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine, 360, 1320-1328. [DOI] [PubMed] [Google Scholar]
  46. Scosyrev E., Messing E. M., Mohile S., Golijanin D., Wu G. (2011). Prostate cancer in the elderly: Frequency of advanced disease at presentation and disease-specific mortality. International Brazilian Journal of Urology, 37, 797-798. [DOI] [PubMed] [Google Scholar]
  47. Shaw E. K., Scott J. G., Ferrante J. M. (2013). The influence of family ties on men’s prostate cancer screening, biopsy, and treatment decisions. American Journal of Men’s Health, 7, 461-471. [DOI] [PubMed] [Google Scholar]
  48. Siegel R., Ma J., Zou Z., Jemal A. (2014). Cancer statistics, 2014. CA: A Cancer Journal for Clinicians, 64, 9-29. [DOI] [PubMed] [Google Scholar]
  49. Sirovich B. E., Schwartz L. M., Woloshin S. (2003). Screening men for prostate and colorectal cancer in the United States: Does practice reflect the evidence? JAMA Journal of the American medical Association, 289, 1414-1420. [DOI] [PubMed] [Google Scholar]
  50. Smith R. A., Cokkinides V., Brawley O. W. (2009). Cancer screening in the United States, 2009: A review of current American Cancer Society guidelines and issues in cancer screening. CA: A Cancer Journal for Clinicians, 59, 27-41. [DOI] [PubMed] [Google Scholar]
  51. Steele C. B., Miller D. S., Maylahn C., Uhler R. J., Baker C. T. (2000). Knowledge, attitudes, and screening practices among older men regarding prostate cancer. American Journal of Public Health, 90, 1595-1600. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Taylor K. L., DiPlacido J., Redd W. H., Faccenda K., Greer L., Perlmutter A. (1999). Demographics, family histories, and psychological characteristics of prostate carcinoma screening participants. Cancer, 85, 1305-1312. [DOI] [PubMed] [Google Scholar]
  53. Volk R. J., Linder S. K., Kallen M. A., Galliher J. M., Spano M. S., Mullen P. D., Spann S. J. (2013). Primary care physicians’ use of an informed decision-making process for prostate cancer screening. Annals of Family Medicine, 11(1), 67-74. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Walter L. C., Fung K. Z., Kirby K. A., Shi Y., Espaldon R., O’Brien S., . . . Hoffman R. M. (2013). Five-year downstream outcomes following prostate-specific antigen screening in older men. JAMA Internal Medicine, 173, 866-873. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Wolf A. M., Nasser J. F., Wolf A. M., Schorling J. B. (1996). The impact of informed consent on patient interest in prostate-specific antigen screening. Archives of Internal Medicine, 156, 1333-1336. [PubMed] [Google Scholar]
  56. Wolf A. M., Schorling J. B. (1998). Preferences of elderly men for prostate-specific antigen screening and the impact of informed consent. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 53, M195-M200. [DOI] [PubMed] [Google Scholar]
  57. Wolf A. M., Wender R. C., Etzioni R. B., Thompson I. M., D’Amico A. V., Volk R. J., . . . Smith RA; American Cancer Society Prostate Cancer Advisory Committee. (2010). American Cancer Society guideline for the early detection of prostate cancer: Update 2010. CA: A Cancer Journal for Clinicians, 60, 70-98. [DOI] [PubMed] [Google Scholar]
  58. Woolf S. H. (1995). Screening for prostate cancer with prostate-specific antigen: An examination of the evidence. New England Journal of Medicine, 333, 1401-1405. [DOI] [PubMed] [Google Scholar]
  59. WWAMI RUCA Rural Health Research Center. (n.d.). Using RUCA data. Retrieved from http://depts.washington.edu/uwruca/ruca-uses.php

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