Determinants of Prostate Cancer Screening in a Sample of African American Military Servicemen

Military Medicine, May 2006 by Joseph, Hyacinth J

This descriptive/cross-sectional study assessed determinants of prostate cancer screening in a sample of African American military servicemen who were age 45 years and older. Data were collected using the Edwards Prostate Perception Survey, a 52-item questionnaire that assessed knowledge, beliefs, self-efficacy, health-related practices, and demographic variables. Despite reporting high knowledge and positive belief about prostate cancer and screening, 43% of the respondents indicated they had never been screened with the prostate-specific antigen blood test, and 27% reported that health care providers had not recommended screening. Respondents were more likely to be screened if they had more knowledge of the prostate-specific antigen test, were retired, older, and when health care providers recommended it. The younger active duty servicemen in the 45 to 50 age group reported the lowest rates of screening.

Introduction

The prevalence of prostate cancer in African American men is a major public health concern.1 Although African American and foreign-born Asian-American men are more likely than Caucasian (European American) men to be diagnosed with advanced disease,2 African American men have the highest incidence and mortality rates in the world.3-5 Epidemiological explanations for these disparities are unknown. However, researchers suggest that African American men, compared to Caucasian men, tend to have less access to health care services, are less knowledgeable of prostate cancer, possess less favorable views about early detection and the consequences associated with treatment, and have less social support to take preventive actions.6-15 The American Cancer Society (ACS) estimated that approximately 232,900 new cases of prostate cancer would be diagnosed in the year 2005 and 30,350 men would die from it.16 Based on current epidemiological trends, it is undisputed that the largest percentage of new cases and deaths will be among African American men.

Prostate cancer is the most commonly diagnosed nondermatological cancer and the second most common cause of cancerrelated deaths among men in the United States.16,17 Primary preventive measures (health promotion strategies) for this disease are unknown and secondary prevention (early detection of the disease through screening) may offer the best possibility of reducing mortality rates. All forms of treatment are most effective when the disease is confined to the prostate. Once metastasis has occurred outside the prostate, the chances of a full recovery are less than optimal.3,15,18 The only means of detecting prostate cancer in its early stages (when it is most curable) is through screening with the digital rectal examination (DRE) and the prostate-specific antigen (PSA) blood test. The ACS recommends that health care providers offer the PSA and DRE tests annually to men beginning at age 50. For high-risk men (African Americans and men with a first-degree relative who was diagnosed with prostate cancer at a young age), the ACS recommends that testing begin at age 45.16 The potential benefit of a screening program is that early detection may save lives and avert complications of tumor progression.17'19 However, screening remains controversial for a number of reasons. The primary objections are related to (a) the reliability of both the PSA and the DRE, (b) an absence of randomized studies showing that screening is effective in reducing mortality rates, and (c) the costs associated with screening and treatment. Current evidence is also insufficient to accurately determine which cancers will progress to become clinically significant and which will not. Given the uncertainty about the benefits of the PSA and DRE, it is recommended that a man's decision to undergo screening for prostate cancer be based on an informed decision, after he has had the opportunity to discuss (with his health care provider) the benefits and limitations associated with the early detection.3,17,19,20

Review of the Literature

Relatively little research has been performed to identify possible predictors of prostate cancer early detection practices among African American men.15 To date, studies have shown that screening decisions may be influenced by a variety of socioeconomic factors. Weinrich et al.11 found that education, ethnicity, and income were all predictors of participation in screening. Men were more likely to report being screened if they had more knowledge of prostate cancer, were Caucasian, or if they had at least a high school education. Urinary symptoms were a predictor of screening for men having annual incomes over $25,000 and a high school education. Men with earnings less than $10,000/year were least likely to report having been screened. Other researchers have reported similar findings.7,12,21,22 Huffman and Gilliland23 found higher rates of screening among men who were retired or insured, received regular medical care, or felt that prostate cancer testing was important. Collins7 found that an unwillingness to undergo annual screening was associated with the way in which the men perceived the importance and convenience of the tests. But further evidence suggests that African American men may be more terrified of cancer than the general population. Although they acknowledge its severity, they tend to underestimate its incidences, are pessimistic about care, and are generally hesitant to seek medical advice when symptoms occur.24,25 In a sample of 613 African American men, those who were younger, had lower incomes, and less education were found to have a more negative attitude toward the DRE than older, high-income, well-educated men. Attitudes toward the DRE became more negative as the fear of cancer increased. Also, men with positive attitudes toward the DRE reported "low to no fear" of cancer. The data further revealed that African American men were not opposed to the DRE test when it is considered a normal part of a physical examination.26 Steele et al.13 found a significantly low percentage of African American men who believed they were at risk for developing prostate cancer. Seven percent perceived themselves to be at high risk for the disease, 43% saw themselves at medium-low risk, 16% felt no risk, and 34% indicated they did not know whether they were at risk. The percentage of men who saw themselves as being at high risk did not vary significantly by age, education, or income.