The Complex Interaction of Race and Social Determinants of Health in Prostate Cancer Screening
Borivoj Golijanin, BS, Vikas Bhatt, MD, Alexander Homer, BS, Elias Hyams, MD.
Minimally Invasive Urology Institute at the Miriam Hospital and Warren Alpert Medical School of Brown University, Providence, RI, USA.
BACKGROUND: Despite stronger evidence and clear recommendations for colorectal carcinoma screening (CRC), patients have historically preferred prostate-specific antigen (PSA) screening. Cancer screening choices may be influenced by more complex interactions of known determinants of healthcare utilization and access including race, socioeconomic status, and general health behaviors. In addition to these social determinants of health (SDOH), shared decision-making (SDM) may augment successful screening practices. Also, SDM is required for responsible, guideline-concordant PSA screening. This study aims to assess the influence of SDOH and SDM on patients who meet the eligibility criteria for PSA screening. METHODS:Responses of individuals meeting the eligibility criteria for PSA screening based on current recommendations were extracted from the 2020 Behavioral Risk Factors Surveillance Survey (BRFSS). Records containing definitive history of SDM and PSA testing were included for analysis. Hierarchical classification of records was used to identify similar clusters. Effects of the multivariable interactions were calculated. All results were weighted. RESULTS:Four distinct clusters were identified within the 30,958 records that met inclusion criteria (Table 1): less diverse, low SES (LD-LS); less diverse, high SES (LD-HS); more diverse, low SES (MD-LS); more diverse, high SES (MD-HS). Rates of SDM were similar between the clusters with 22% in LD-LS, 23.36% in LD-HS, 20.34% in MD-LS, 19.9% in MD-HS. For the four groups, LD-LS, LD-HS, MD-LS, and MD-HS, PSA screening rates were significantly different with 48.6%, 49.5%, 39.59%, and 39.52%, respectively; CRC screening rates were similar with 81.6%, 84.1%, 78.5%, and 77.2%, respectively. SDM was associated increased odds of PSA testing in all groups, MD-LS demonstrated the highest increase (OR=4.64, CI=4.63 - 4.65), followed by MD-HS (OR=3.69, CI=3.68 - 3.69), LD-LS (OR=3.21, CI=3.21 - 3.21), and LD-HS (OR=3.06, CI=3.06 - 3.06). CONCLUSIONS:Naturalistic analysis of the BRFSS data allowed for identification of unique groups with distinct healthcare behaviors representing differences between PSA screening-eligible patients. Social determinants and behavioral choices interact with SDM, which remains low across all groups, and affect cancer screening rates. Importantly, differences in SDM and PSA screening exist within the same racial groups when considering SES and within the same SES level when considering race. Additional investigation into the interplay of SDOH and personal choices can further elucidate on how to improve cancer screening practices in this patient population.
Table 1: Sociodemographic characteristics of clusters identified in BRFSS. All values are weighted. 95% confidence intervals are in brackets.
| Trait | Less Diverse, Low SES (LD-LS) | Less Diverse, High SES (LD-HS) | More Diverse, Low SES (MD-LS) | More Diverse, High SES (MD-HS) |
| Demographic/Socioeconomic | ||||
| Age | 64 [64-64] | 62 [62-62] | 62 [61-62] | 62 [62-63] |
| Cost Barrier to Healthcare (%) | 7% [7%-7%] | 3% [3%-3%] | 17% [17%-17%] | 10% [10%-10%] |
| Education (no school, 0%, to college graduate, 100%) | 70% [70%-70%] | 87% [87%-87%] | 47% [47%-47%] | 63% [63%-63%] |
| White Racial Identity (%) | 90% [89%-91%] | 100% [100%-100%] | 1% [0%-2%] | 28% [26%-30%] |
| Black Racial Identity (%) | 0% [0%-1%] | 0% [0%-0%] | 38% [34%-41%] | 24% [22%-26%] |
| American Indian/Pacific Islander Racial | Identity (%) 0% [0%-0%] | 0% [0%-0%] | 9% [7%-12%] | 5% [4%-6%] |
| Asian Racial Identity (%) | 6% [5%-6%] | 0% [0%-0%] | 2% [1%-3%] | 10% [8%-11%] |
| Native Hawaiian Racial Identity (%) | 1% [1%-1%] | 0% [0%-0%] | 1% [0%-2%] | 1% [1%-2%] |
| Other Racial Identity (%) | 0% [0%-0%] | 0% [0%-0%] | 12% [10%-15%] | 1% [0%-1%] |
| Multiracial Racial Identity (%) | 0% [0%-0%] | 0% [0%-0%] | 16% [14%-19%] | 8% [6%-9%] |
| Hispanic Racial Identity (%) | 3% [2%-4%] | 0% [0%-0%] | 21% [18%-24%] | 23% [21%-26%] |
| Married (%) | 57% [56%-59%] | 77% [76%-78%] | 31% [28%-35%] | 48% [45%-50%] |
| Divorced (%) | 11% [10%-12%] | 21% [20%-22%] | 7% [5%-9%] | 16% [14%-18%] |
| Widowed (%) | 7% [6%-8%] | 0% [0%-0%] | 14% [12%-17%] | 14% [12%-16%] |
| Separated (%) | 2% [2%-3%] | 0% [0%-0%] | 12% [10%-15%] | 3% [2%-4%] |
| Single (%) | 20% [19%-21%] | 2% [2%-2%] | 25% [22%-29%] | 11% [10%-13%] |
| Non-Married Couple (%) | 2% [1%-2%] | 0% [0%-0%] | 9% [7%-11%] | 7% [6%-8%] |
| Rent Housing (%) | 21% [21%-21%] | 6% [6%-6%] | 60% [60%-60%] | 33% [33%-33%] |
| Health Behaviors | ||||
| Report Regular Exercise (%) | 70% [70%-70%] | 86% [86%-86%] | 60% [56%-64%] | 71% [71%-71%] |
| Report Regular Check Up | 92% [92%-92%] | 86% [86%-86%] | 92% [92%-92%] | 91% [91%-91%] |
| Smoker Status (%) | 57% [57%-57%] | 38% [38%-38%] | 58% [58%-58%] | 54% [54%-54%] |
| Received Flu Vaccine (%) | 65% [65%-65%] | 48% [48%-48%] | 55% [55%-55%] | 53% [53%-53%] |
| Received Pneumonia Vaccine (%) | 55% [55%-55%] | 31% [31%-31%] | 47% [47%-47%] | 41% [41%-41%] |
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