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Primary Care Providers' Attitudes Toward Prostate Cancer Risk Factors at a Veterans Affairs Health Care Facility

Posted on: Thursday, 24 February 2005, 03:00 CST

Objective: We asked what factors influence primary care providers' decision to screen patients for prostate cancer. Methods: A survey completed by 175 Veterans Affairs primary care providers queried whether patient anxiety, family history, race, and other assorted risk factors increased their likelihood of screening for prostate cancer. Subsequent questions assessed the degree to which various factors, such as age, comorbidities, and lack of interest, decreased their likelihood of screening. Results: The African American race increased the tendency for screening for 84.6%, followed by a family history of prostate cancer for 73.3%. Life expectancy of less than 5 years substantially decreased the tendency to screen for only 42.3%. Only 28% thought that age of more than 75 years was a deterrent to screening. Conclusions: Veterans Affairs primary care providers recognize the need to aggressively screen African Americans and men with a family history of prostate cancer. However, they often screen men with a limited life expectancy or advanced age.

Introduction

Divergent recommendations for prostate cancer screening have been promoted among primary care providers.1-12 Those groups supporting screening rely on indirect evidence, such as the decreased prostate cancer mortality rates and stage migration observed since the advent of prostate cancer screening.1-4 Groups opposing prostate cancer screening cite the cost, high false-positive rate, lack of prospective survival data, and morbidity of prostate cancer therapy reported for the Medicare population.5-12

The conflict is heightened by reports in the general medical literature and the lay press suggesting that certain patient groups are at higher risk for prostate cancer. Reported risk factors include the African American race,13-17 family history of prostate cancer,15-18 previous vasectomy,16,17,19,20 tobacco use,21-23 and Agent Orange exposure.24-26 Most studies refuting or supporting these risk factors have been published in the urological literature. The personal characteristics of primary care providers can also create subtle biases.27-31 We sought to determine what risk factors influence the decision of primary care providers to screen and/or refer patients to the urology clinic for prostate cancer diagnostic evaluation, by conducting a survey of primary care providers affiliated with a large medical center.

Methods

A survey was circulated to 220 primary care providers at Veterans Affairs health care facilities, of whom 175 (102 physicians and 73 nurse practitioners) replied. The questionnaire initially queried whether the following factors did not increase, somewhat increased, or substantially increased their likelihood of encouraging a patient to undergo screening for prostate cancer: family history of prostate cancer, African American race, history of vasectomy, history of exogenous androgen administration, history of smoking, history of Agent Orange exposure, or patient anxiety about prostate cancer. Subsequent questions asked whether the following factors did not decrease, somewhat decreased, or substantially decreased their likelihood of encouraging a patient to undergo screening for prostate cancer: lack of patient interest in screening, significant cardiac or pulmonary disease, previous malignancy, life expectancy of less than 5 years, life expectancy of less than 10 years, spinal cord injury, Asian race, age of less than 50 years, age of less than 60 years, age of more than 70 years, age of more than 75 years, or age of more than 80 years.

Responders were also asked about their race, gender, age, whether they were U.S. veterans, and whether they or their spouses/partners had undergone a vasectomy or had a family history of prostate cancer.

Results

Of the responders, 74 (42.3%) were male and 64 (36.6%) were female (some declined to state a gender). There were 93 (53.1%) providers 50 years of age or younger, while 36 (20.6%) were between 51 and 60 years of age and 19 (10.8%) were more than 60 years of age. None of the responders reported a family history of prostate cancer, whereas 18 (10.3%) stated that either they or their spouses had undergone a vasectomy; 35 (20.0%) were veterans. There were 23 (13.1%) responders who listed their race as African American, 123 (70.3%) were Caucasian, and 29 (16.8%) listed other races or declined to state a race.

African American race of the patient either somewhat or significantly increased the tendency for screening for 148 (84.6%) practitioners, followed by a family history of prostate cancer for 130 (74.3%) as shown in Figure 1. Histories of smoking and vasectomy prompted 43.4% and 28.6% of providers, respectively, to be either somewhat or significantly more likely to screen for prostate cancer. The influences of African American race, family history, smoking, and vasectomy on screening tendencies were not biased by responders' age, gender, race, vasectomy status, or veteran status. Overall, 36 (20.6%) providers stated that a history of Agent Orange exposure significantly increased their tendency to screen for prostate cancer. This factor was also not influenced by the age, gender, race, vasectomy status, or veteran status of the provider. Specifically, providers who served in the military did not have an increased tendency to screen patients with Agent Orange exposure, compared with nonveteran providers, with 7 (20.0%) veterans stating that they were significantly more apt to screen for prostate cancer among patients with a history of Agent Orange exposure.

Fig. 1. Bar graph depicting the degree to which various risk factors prompt primary care providers to screen for prostate cancer.

Overall, patient anxiety about prostate cancer either somewhat or significantly increased the tendency to screen for 71.2% of providers. Of the 53 providers between 41 and 50 years of age, 50 (94.3%) were strongly influenced by patient anxiety about cancer, whereas more than 90% of providers less than 40 years or more than 50 years of age denied patient anxiety as a factor in their decisions to screen for prostate cancer. There was no significant difference between male and female providers in factors reported to somewhat or substantially increase their tendency to screen for prostate cancer (Table I), with the exception of patient anxiety about prostate cancer, which was more likely to prompt female providers to screen for the disease (p = 0.013).

Life expectancy of less than 5 years was the biggest deterrent to screening, but only 74 (42.3%) practitioners thought that this either somewhat or significantly decreased their tendency toward screening (Fig. 2). Surprisingly, only 49 (28.0%) and 67 (38.3%) providers thought that patient age of more than 75 years and 80 years, respectively, substantially decreased their tendency to screen for prostate cancer (Fig. 3). Of the providers who thought that patient age of more than 80 years was not a deterrent to screening, 34 (50.7%) were more than 60 years of age and the remaining 33 (49.3%) were more than 50 years of age. Providers less than 50 years of age uniformly thought that patient age of more than 80 years dissuaded them from screening for prostate cancer. In contrast, the tendency to screen patients more than 75 years of age was evenly distributed across the provider age groups. There was no significant difference in the responses of female and male providers regarding any of the factors examined for potentially discouraging prostate cancer screening. There was a trend toward a more liberal tendency to screen for prostate cancer among nurse practitioners than physicians, but this did not reach statistical significance.

TABLE I

PRIMARY CARE PROVIDER GENDER DIFFERENCES AMONG FACTORS REPORTED TO SOMEWHAT OR SUBSTANTIALLY INCREASE THE TENDENCY TO SCREEN FOR PROSTATE CANCER

Fig. 2. Bar graph depicting the degree to which various risk factors dissuade primary care providers from screening for prostate cancer.

Fig. 3. Bar graph depicting the degree to which patient age dissuades primary care providers from screening for prostate cancer.

Discussion

Primary care providers are subjected to mixed recommendations for prostate cancer screening from various organizations.w2 The U.S. Preventive Services Task Force has indicated that there is no current evidence to support annual prostate-specific antigen (PSA) testing and digital rectal examinations for men more than 50 years of age.9 The American Academy of Family Physicians recommends counseling men between the ages of 50 and 65 years about the known risks and uncertain benefits of screening for prostate cancer.10 Similarly, the American College of Physicians recommends that, rather than routinely screening all men for prostate cancer, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen.11 The American Urological Association currently recommends that all men 50 years of age or older should have an annual prostate examination (digital rectal examination and PSA test) and all men 40 years of age or older with a family history of prostate cancer should have an annual prostate examination (digital rectal examination and PSA test).1 The American Cancer Society has issue\d guidelines on prostate cancer screening that fall between those of the American College of Physicians and the American Urological Association. According to the American Cancer Society, an annual prostate examination, including a digital rectal examination and a PSA test, should be offered to men with a life expectancy of at least 10 years beginning at age 50 and should be offered to younger men who are at high risk.2 The American Cancer Society emphasizes the benefits of beginning annual screening at age 45 in certain high-risk populations. The generally well-known high-risk groups include African American men and men with two or more first-degree relatives with prostate cancer. Several studies have shown that these American Cancer Society recommendations are the most widely accepted by primary care providers.32-34

We found that primary care providers at Veterans Affairs facilities recognized the need to aggressively screen African American men and men with a family history of prostate cancer. In 2003, however, as in the early and middle 1990s,35-37 primary care providers were not as dissuaded from screening by limited life expectancy or advanced age as would be expected with current recommendations.

Patient and/or family anxiety was a strong motivator for some providers to screen for prostate cancer. Women providers were particularly influenced by patient/family anxiety. This may be partially explained by the findings of Lurie et al.,28 who found that female providers were less confident about their ability to detect prostatic abnormalities in digital rectal examinations. The tendency for patients' wives to be more anxious to pursue prostate cancer screening than the patients themselves might also have an influence on female providers.38 Contrary to the findings of Edlefsen et al.,27 we found that younger male and female physicians were more likely to screen for prostate cancer than were older male physicians.

Our study did not include questions about practice arrangements or patient insurance coverage. Others showed that physicians with university affiliations and those in multiphysician private practice groups were more likely to screen for prostate cancer than were those in solo private practice.27,30 The tendency to screen has also been found to increase with increasing quality of patient insurance coverage.27,30,34

Another issue we did not address was the perceived medicolegal risk associated with prostate cancer screening. Previous studies showed that up to 80% of primary care providers thought that a man 65 years of age could win a malpractice suit against his primary care physician for not screening if the patient was subsequently diagnosed with prostate cancer.39 In the same study, although only 27% of primary care providers thought that the patient should "win" such a suit, 78% screened men in this age group.39 It is known that failure to diagnose cancer is the most frequent malpractice claim in the United States.40 For liability to be established, however, it is necessary to establish that a standard of care exists and was not met in an individual case; it must also be proven that earlier diagnosis would have made a difference in outcome/prognosis.41 For prostate cancer, the accepted standard of care varies from organization to organization, and speculation about the prediagnosis tumor growth rates is very inexact. As a result, judgment outcomes are not always predictable. Defensive medicine may actually set the standard of care for primary care physicians,42 rather than knowledge or understanding of the implications of screening. This may help explain the divergence in screening patterns between urologists and primary care physicians.

A duplicate study is currently underway to assess screening attitudes in the rural Southeast for comparison to these findings in an urban Northwest setting. Additional questions regarding type of practice setting, patient insurance coverage, and malpractice fears have been added to the questionnaire.

References

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Guarantor: Martha K. Terris, MD

Contributors: Peter A. Ruff, MD*; Jeffrey B. Marotte, MD[dagger][double dagger]; Martha K. Terris, MD*[double dagger]

* Section of Urology, Medical College of Georgia, Augusta, GA 30904.

[dagger] Department of Urology, Stanford University Medical Center, Stanford, CA 94305.

[double dagger] Section of Medical Urology, VA Palo Alto Health Care System, Palo Alto, CA 94304.

Presented at the Annual Meeting of the Southeastern section, American Urological Association, March 30, 2003, Savannah, GA.

This manuscript was received for review in November 2003. The revised manuscript was accepted for publication in March 2004.

Reprint & Copyright by Association of Military Surgeons of U.S., 2005.

Copyright Association of Military Surgeons of the United States Feb 2005

Source: Military Medicine

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