Racial Disparities in Patient Perspectives on Shared Decision Making in Prostate Cancer Screening Following 2018 Guideline Changes

Abstract

<h3>Purpose/Objective(s)</h3> The 2018 US Preventive Services Task Force (USPSTF) guidelines recommend individualizing prostate cancer screening in 55–69-year-old men with discussion of risks, benefits, values, and preferences. Given the two-fold higher incidence of prostate cancer in African-American (AA) compared to non-Hispanic white (NHW) men, we compared patient perspectives on shared decision making on prostate specific antigen (PSA) screening, hypothesizing that the rate of screening and discussion of risks/benefits would not be commensurate with the relative risk between these two groups. <h3>Materials/Methods</h3> We used the Behavioral Risk Factor Surveillance System's nationwide survey data on screening-eligible men based on these guidelines to assess patterns of PSA testing. We also performed subset analysis of men interviewed on perspectives of shared decision making for PSA screening. We used weighted Poisson regression and Kruskal-Wallis rank sum tests to compare the rate of PSA screening in the past 2 years; rate of shared, individual, and provider decision to perform PSA testing; and patient-reported education on PSA advantages and disadvantages. <h3>Results</h3> We identified 43,685 men (40,301 NHW and 3,384 AA) aged 55-70 interviewed about PSA screening in 2020. AA men were more likely than NHWs to be uninsured (10.5% versus 5.6% p<0.001) and to report cost barriers to accessing care (10.7% versus 5.5% p<0.001). AA men reported 12.8% lower rate of screening (95% confidence interval (95% CI) -12.6 to -13.0 p<0.001) than NHWs. Estimates remained similar and statistically significant in multivariable and sequential regression analyses adjusting for socioeconomic and care access factors. AA and NHW men reported similar rates of education regarding advantages of PSA screening: 54.6% and 55.4%, respectively (p = 0.38), although AA men were significantly more likely than NHWs to report education on disadvantages of screening: 32% versus 24.6% (p<0.001). Finally, in subset analysis of 735 men asked about who made the decision to undergo PSA screening, AA men were 31.8% less likely to report a shared decision with their provider (95% CI -30.2 to -33.3 p<0.001) and 14.6% (95% CI 12.5 to 16.6 p<0.001) more likely to report making the decision themselves than NHWs. <h3>Conclusion</h3> Despite prostate cancer being more common and fatal in AA than NHW men, PSA screening and education patterns do not reflect this increased risk even when adjusting for socioeconomic and health access disparities. In addition to lower PSA screening rates, AA men reported lower rates of shared decision making than NHW men and a greater recollection of education on the disadvantages of PSA screening. This could represent distrust in the medical system by AA men, as well as systemic racial bias leading to reduced screening or poorer communication with AA men. Overall, these findings suggests that there remains room for improvement in how physicians address risk stratification and racial biases in counseling patients on PSA screening.