Prostate Cancer Screening among Military Service Members

Military Medicine,  Apr 2004  by Joseph, Hyacinth J,  Hickey, James R

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This retrospective study investigated the characteristic of military male beneficiaries age 50 years and older who were screened for prostate cancer at a medical center in the Pacific Regional Command. Data were collected on male patients who were seen in three adult outpatient clinics from December 1999 through November 2001. Two research questions were asked: What are the characteristics of men age 50 and older who were screened for prostate cancer? Are there variations in prostate cancer screening based on age, ethnicity, and military status? Data were analyzed using descriptive statistics. The sample was predominantly Caucasian and Asian/Pacific Islander who were over age 67. Although there was evidence of screening in 68% of the sample, 13% of the men had been screened according to the American Cancer Society's recommendations. The findings support the need for a prostate cancer screening policy for the Department of Defense.

Introduction

Every 24 hours, prostate cancer claims the lives of over 80 American men.1 The American Cancer Society estimated that there were 220,000 new cases of prostate cancer with approximately 28,900 deaths in 2003.2 Wide variations in the incidences and survival rates have been reported among men from different ethnic and racial groups. African-American men develop prostate cancer at a higher rate than men in any other racial or ethnic group, and have dramatically higher mortality rates as well.1,3-6 When compared with Caucasian men, African-American men have an 84% greater risk of developing prostate cancer and a 114% greater risk of dying from the disease.7,8 In contrast, Asian/Pacific Islanders have the lowest incidences and mortality rates of all ethnic and racial groups. Epidemiological explanations for these disparities are unknown. However, the literature suggests that African-American men are diagnosed with more advanced stages of the disease, which significantly impacts their survival rates.5,9 Although some authors cite differences in socioeconomic status, a lack of awareness, and limited access to health care as major contributing factors,10,11 there is evidence that similar disparities continue to occur, even in instances of equal access to care.12

Preventable risk factors for prostate cancer are unknown. The only known secondary measures are screening for and treating the disease at an early stage. Within recent years, researchers have attributed an increase in the early identification of prostate cancer to the use of the digital rectal examination (DRE) and the prostate specific antigen (PSA) test.2,4,5,9 The American Cancer Society now recommends annual DRE and PSA testing for all men 50 years of age and older. Men at risk (African American and those who have a first-degree relative diagnosed with prostate cancer at a young age) should begin screening at age 45.2 Due to inherent weakness with the PSA and DRE, the best option for a diagnosis occurs when both procedures are used in combination.2,4,9

The Department of Defense (DOD) does not have a policy on prostate cancer screening. Researchers at the DOD Center for Prostate Disease Research (CPDR) indicate that a lack of data based on randomized studies has kept the government from establishing specific recommendations.13 However, military scientists acknowledge the growing disparities among racially and ethnically diverse men and recommend "radically focused awareness initiatives." They believe that if men from high-risk groups (such as African Americans) were diagnosed with earlier stages of the disease, they would probably be better candidates for surgical interventions.12

The results of a longitudinal study by CPDR scientists has underscored the lifesaving value of routine prostate cancer screening. The findings in a sample of 800 military patients who underwent surgery for prostate cancer revealed that the stage of the cancer at the time of surgery changed dramatically during the era of DRE and PSA screening. In 1989, 20% of patients having prostate surgery had cancer that had spread beyond the prostate. In 1998, that percentage had dropped to 3%. Furthermore, the study found that among African-American men, the drop in the rate of advanced disease had been greater than among Caucasian men. It was initially thought that African-American men were prone to develop a more biologically aggressive cancer than Caucasian men. The findings of this study did not support that theory. Instead, CPDR scientists believe that with early detection, African-American and Caucasian men could have basically the same outcome.14

Methods

The purpose of this study was to investigate the characteristics of military male beneficiaries age 50 and older who were screened for prostate cancer. Two research questions were asked: What are the characteristics of men age 50 and older who were screened for prostate cancer? Are there variations in prostate cancer screening based on age, ethnicity, and military status? A datasheet developed by the investigators solicited information on age, race/ethnicity, military status, DRE and PSA and date completed, clinic where care was provided, and whether screening was offered and refused by the patient. The study protocol was approved by the Human Use Committee at Tripler Army Medical Center. Investigators adhered to the policies for the protection of human subjects as prescribed in 45 CFR 46.