We used data from the nationally representative Behavior Risk Factor Surveillance System (BRFSS), which was designed to monitor the prevalence of preventive care-seeking and healthy lifestyles at state and national levels in the United States.6
We included surveys from 2006 to 2020, retaining even years where questions about PSA screening were asked (receipt of PSA test within the past 2 years). Men aged 55-69 years, without a prior history of prostate cancer were included. Access barriers and facilitators were chosen based on Penchansky and Thomas’ framework through questions related to affordability (insurance, costs that prohibited care seeking) and accommodation (having a regular primary care provider, having a physician recommend screening).7 For availability and physical access, we calculated a spatial accessibility index. The BRFSS provides data at the Metropolitan and Micropolitan Statistical Area geographical scale, which are slightly larger than counties. Using this geographical scale, we were able to append measures of estimated travel time to closest healthcare facility8 and county-level density of oncology and primary care providers9 to compute a spatial accessibility index, and thereby evaluate physical access and availability as potential barriers to accessing screening. We then studied associations between affordability, accommodation, and spatial accessibility with receipt of PSA screening and evaluated whether associations varied by race, education, and area-level socioeconomic status.
We found that a doctor’s recommendation for screening was far and away the strongest facilitator of screening (roughly 16-fold increased odds), although lack of insurance, reporting unaffordable care, and not having a regular primary care provider were all associated with lower odds of screening. The spatial accessibility index was not robustly correlated with screening. Associations of barriers with PSA screening were generally weaker among Black and Hispanic compared to White and Asian individuals, and among those with less than a high school education compared to those with higher education. Higher spatial accessibility index was associated with higher receipt of PSA testing only among those in the highest quintile of area-level socioeconomic status.
Limitations of the study include potential selection bias and lack of generalizability of the study sample, which may be skewed towards older, more affluent, and better-educated individuals. We incorporated survey weights to mitigate this bias. We were unable to link smaller area estimates of spatial accessibility, which may have led to measurement error. However, healthcare systems typically serve large catchment areas and so these geographic areas may be appropriate for understanding larger geographic patterns in care-seeking. These findings highlight the importance of regular contact with a primary care physician, and their beliefs on the benefits and harms of screening, in driving screening patterns in high-risk men.
Written by: Hari Iyer, ScD, MPH, Cancer Epidemiologist, Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
References:
- Andriole GL, Crawford ED, Grubb RL, Buys SS, Chia D, Church TR, et al. Mortality Results from a Randomized Prostate-Cancer Screening Trial. N Engl J Med. 2009 Mar 26;360(13):1310–9.
- Schröder FH, Hugosson J, Roobol MJ, Tammela TLJ, Zappa M, Nelen V, et al. The European Randomized Study of Screening for Prostate Cancer – Prostate Cancer Mortality at 13 Years of Follow-up. Lancet. 2014 Dec 6;384(9959):2027–35.
- Etzioni R, Penson DF, Legler JM, di Tommaso D, Boer R, Gann PH, et al. Overdiagnosis Due to Prostate-Specific Antigen Screening: Lessons From U.S. Prostate Cancer Incidence Trends. JNCI: Journal of the National Cancer Institute. 2002 Jul 3;94(13):981–90.
- Garraway IP, Carlsson SV, Nyame YA, Vassy JL, Chilov M, Fleming M, et al. Prostate Cancer Foundation Screening Guidelines for Black Men in the United States. NEJM Evidence. 2024 Apr 23;3(5):EVIDoa2300289.
- Kensler KH, Johnson R, Morley F, Albrair M, Dickerman BA, Gulati R, et al. Prostate Cancer Screening in African American Men: A Review of the Evidence. JNCI: Journal of the National Cancer Institute. 2023 Sep 15;djad193.
- Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention;
- Penchansky R, Thomas JW. The Concept of Access: Definition and Relationship to Consumer Satisfaction. Medical Care. 1981;19(2):127–40.
- Weiss DJ, Nelson A, Vargas-Ruiz CA, Gligorić K, Bavadekar S, Gabrilovich E, et al. Global maps of travel time to healthcare facilities. Nature Medicine. 2020 Dec;26(12):1835–8.
- Bureau of Health Professions. User Documentation for the Area Health Resource File (AHRF) 2012-2013 Release. U.S. Department of Health and Human Services; 2013.