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Family History, Perceived Risk, and Prostate Cancer
Screening among African American Men
Joan R. Bloom, Susan L. Stewart, Ingrid Oakley-Girvans, et al.
Cancer Epidemiol Biomarkers Prev 2006;15:2167-2173.
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2167
Family History, Perceived Risk, and Prostate Cancer
Screening among African American Men
Joan R. Bloom,1 Susan L. Stewart,2 Ingrid Oakley-Girvans,3 Priscilla Jane Banks,3 and Subo Chang3
University of California, Berkeley, Berkeley, California; 2University of California, San Francisco, San Francisco, California;
and 3Northern California Cancer Center, Fremont, California
1
Abstract
Background: Many African American men have two major
risk factors for prostate cancer. By ethnicity alone, they have
twice the risk of Euro-American men of developing prostate
cancer. Having a family history (brother or father with
prostate cancer) also doubles their risk. The major hypotheses tested in this study are that men with a family history
perceive their risk to be higher, are more worried about
getting prostate cancer, and are more likely to have used
cancer screening tests than men without such a history.
Methods: A sample of 208 African American men, ages 40 to
74 years, were recruited through relatives or friends whose
prostate cancer diagnosis was reported to the California
Cancer Registry during the years 1997 to 2001 and from
churches and African American social groups. Following a
screening interview to determine eligibility, 88 men with
self-reported, first-degree family history of prostate cancer
and 120 without such history were interviewed by telephone.
Logistic regression was used to create models of perceived
risk, prostate cancer worries, receipt of a digital rectal exam,
and/or prostate-specific antigen (PSA) testing.
Results: Men with a self-reported family history of prostate
cancer did not perceive their risk as higher than men without a
family history, nor did they report more cancer worries. They
were more likely to report having a recent PSA test, but not a
digital rectal exam. Having a higher than average perceived
risk was associated with younger age, a college education, and
lower mental well-being, and reporting more prostate cancer
worries and being more likely to have had a recent PSA test.
Conclusions: Although there continues to be controversy about
PSA testing, these data suggest that African American men
at above-average risk are inclined to be screened. (Cancer
Epidemiol Biomarkers Prev 2006;15(11):2167 – 73)
Introduction
It is estimated that over 232,000 men in the United States will
be diagnosed with prostate cancer in 2005, and an estimated
30,350 men will die from this disease (1). Prostate cancer is the
second leading cause of cancer death nationwide for men over
age 60 years (2). The lifetime risk of developing prostate cancer
and dying increases substantially after the age of 50 years (3).
Age-adjusted prostate cancer incidence rates are >50% higher,
and age-adjusted mortality rates are twice as high, among
African American men as among Euro-Americans (3). Along
with race/ethnicity and age, a family history of prostate cancer
is also a well-established risk factor. In fact, a family history of
prostate cancer has been identified as the strongest known risk
factor. Men that have a brother or father with prostate cancer
have a 2- to 4-fold increased risk of developing prostate cancer.
A 5- to 11-fold increased risk has been noted among men with
two or more affected relatives, depending on the number of
relatives who have prostate cancer and whether they are firstor second-degree relatives (4-6). Relative risk is also inversely
related to the person’s age and the age of the affected family
members.
Thus, many African America men have two major risk
factors, ethnicity and family history. Whittemore et al. (6)
considered African American as well as Asian American men
in their case control study of prostate cancer risk in North
America. The overall odds ratio (OR) for family history,
adjusted for age, region of residence, and ethnicity was 2.5,
Received 9/26/05; revised 8/21/06; accepted 8/29/06.
Grant support: Special Interest Grant to the University of California Berkeley Prevention
Center from Department of Health and Human Services, The Centers for Disease Control and
Prevention.
The costs of publication of this article were defrayed in part by the payment of page charges.
This article must therefore be hereby marked advertisement in accordance with 18 U.S.C.
Section 1734 solely to indicate this fact.
Requests for reprints: Joan R. Bloom, School of Public Health, University of California, 409
Warren Hall, Berkeley, CA 94720-7360. Phone: 510-642-4458; Fax: 510-643-6981.
E-mail: [email protected]
Copyright D 2006 American Association for Cancer Research.
doi:10.1158/1055-9965.EPI-05-0738
and the OR did not differ significantly by race. Although the
proportion reporting only second-degree relatives with prostate cancer did not differ between cases and controls, men
reporting at least one first-degree relative were at increased
risk. Relative to men with no first-degree relatives with
prostate cancer, the risk among those with an affected brother
was slightly higher than those with an affected father or son
(OR 2.9 compared with 2.0), whereas the OR for both a brother
and a father or son was 6.4 (6).
A substantial proportion of men with a family history or
other risk factors remain unaware of their heightened risk (7).
In a study of 139 first-degree relatives of men with prostate
cancer, of the 105 men who knew about their familial risk, only
62% believed that they were at higher risk than the average
man (8). A survey of African American and Euro-American
men interviewed during National Prostate Awareness week in
1992 found low knowledge regarding risk factors for prostate
cancer. Only 41% of African American men and 56% of EuroAmerican men knew that heredity could increase prostate
cancer risk, whereas 53% of African American men and of 33%
Euro-American men were aware that race was a risk factor (9).
Two recent studies of African American men reported poor
knowledge of prostate cancer with the average percentage of
correct screening information being 61.9% and 68.4%, respectively. In the latter study, family history was related to
screening behavior (10, 11). The Behavioral Risk Factor Survey
(12) in New York found that 9% of men perceived themselves
to be at ‘‘high’’ risk and 18% perceived that they were at ‘‘no
risk.’’ Those that perceived themselves to be at no risk were
older and had less education and lower income. However, in a
special survey of African American men, 7% perceived that
they were at high risk of developing prostate cancer and 16%
believed themselves to be at no risk. Among African American
men, being at high risk versus no risk did not vary
demographically (12). Finally, a study of urban and rural
men in Georgia reported that rural African American men had
the lowest knowledge of prostate cancer risk factors, only 10%
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2168 Prostate Cancer Screening
of rural and urban African American men and rural EuroAmerican men perceived their risks of prostate cancer to be
high (13).
Men with a family history of prostate cancer report cancer
worries that may increase symptoms of depression and
compromise function in daily life (9). At the same time, 60%
of the family members of the men wanted to know what
their risk was; the desire to know was related to having a son,
other children, and a father whose prostate cancer treatment
had a curative intent. Although cancer worries may have
motivated men to seek information regarding their risk and
screening for prostate cancer, higher levels of anxiety were
related to reduced screening (14). In a U.S. study, Taylor
et al. (15) also found that psychological distress was greater
for those reporting high perceived risk. These findings
are interpreted as suggesting that moderate anxiety enhances
action on the part of the individual, whereas high levels
of anxiety are inhibiting. However, in another study, men
with a family history of prostate cancer (half of the sample
of 166 men) reported greater perceived vulnerability and
were more likely to report their intention to be screened and
to have been screened in the past. Perceived vulnerability
mediated the relationship between family history and intention to be screened (16). In summary, recent studies indicate
that heightened perception of cancer risk and moderate
worries are strong predictors of screening (17-19).
The primary purpose of this study is to describe the
extent to which African American men are aware of prostate cancer as a serious threat to their health, are aware of
their risk of prostate cancer based on their race and family
history, are knowledgeable about prostate cancer, and have
used early detection methods [digital rectal exam (DRE),
prostate-specific antigen (PSA) testing]. The major hypotheses
tested are that men with a first-degree family history of
prostate cancer perceive their risk to be higher, are more
worried about getting prostate cancer, and are more likely to
have recently used early detection methods than men without
such history.
Materials and Methods
Conceptual Framework. The foregoing argument follows
from the Health Belief Model (20), which is used to understand
why people accept preventive health services and why they do
or do not adhere to health regimens. In general, the model
suggests that individuals will take action if they believe
themselves to be susceptible to what they perceive to be a
serious threat to their health. Perceived susceptibility refers to
one’s subjective perception of the risk of contracting a health
condition, e.g., prostate cancer. Perceived severity refers to the
seriousness of the condition if left untreated. The second
component of the theory refers to the perceived benefits of the
actions one can take to reduce the threat. Thus, if a man
perceives that getting screened will reduce the threat, he will
be more likely to get screened. The action that he would take
must be perceived as feasible and efficacious. Finally, the
potential negative aspects of a particular health action, or
perceived barriers, may act as impediments to taking action.
Thus, in Rosenstock’s words, ‘‘The combined levels of
susceptibility and severity provide the energy or force to act
and the perception of benefits (less barriers) provides a
preferred path to action.’’ (20). With regard to prostate cancer
screening, men with a family history will perceive themselves
as more vulnerable so that the benefits will outweigh the
barriers (sensitivity of the PSA test and consequences of cancer
treatment) and they will be likely to have received a recent test.
Men without a family history will not perceive themselves to
be vulnerable so that the barriers will outweigh the benefits
and they will be less likely to be screened.
Procedures. Eligible African American men were recruited
through relatives or friends whose prostate cancer diagnosis
before age 75 years was reported to the California Cancer
Registry during the years 1997 to 2001. Due to difficulties
reaching potentially eligible subjects without a family history
of prostate cancer, we also recruited men from churches and
African American social groups. Following a screening
interview to determine eligibility, men with asked to refer
their brother, son, or a friend/acquaintance to the study.
After gaining permission to contact the brother/son or
friend, a trained interviewer ascertained eligibility and conducted a 30-minute telephone interview to assess physical and
mental health status, awareness of prostate cancer risk,
screening behavior, and knowledge of prostate cancer. For
reasons of confidentiality a brother, son, or friend referred by a
prostate cancer survivor was not informed that someone with
prostate cancer had referred him to the study. We developed a
close-ended, structured telephone interview and trained the
four interviewers to administer it in English in a consistent
way. Periodically, they also met to discuss issues that came up
regarding its administration. The Institutional Review Boards
of the participating institutions approved the conduct of the
study.
Sample. Of 899 prostate cancer cases reported to the
registry, 134 did not have a phone number and 49 did not
have a phone number or an address. Six cases were excluded
because their physicians advised against contacting them, 21
did not fit the sampling criteria, 42 had died, 25 were too ill,
247 refused, 59 could not be reached after 20 attempts, and
8 had not been interviewed by the end of recruitment. The 308
men who were reached and screened for having eligible family
members or friends (if no eligible family members) referred
199 potential participants (Fig. 1).
Of the 199 referrals from prostate cancer survivors, 96
agreed to participate and completed the survey (70 brothers/
sons and 26 without a self-reported first-degree family
history), 26 refused, 9 did not have a phone number, 8 were
not eligible or too ill, 25 could not be reached after 20 attempts,
and 35 were not interviewed by the end of the study.
Of 222 referrals from African American community groups
(including churches), 112 completed the survey (18 brothers/
sons of men with prostate cancer and 94 without a family
history of prostate cancer). Of the remaining, 7 were ineligible,
3 did not have a phone number, 8 refused, 14 could not be
reached after 20 phone calls, and 78 were not interviewed as
recruitment was complete. The final sample included 208 men,
ages 40 to 74 years, 88 men with a self-reported first-degree
family history of prostate cancer, and 120 without such a
history. This sample size provides 80% power to detect at the
0.05 level (two sided) a difference of 20 percentage points
between men with and without a family history of prostate
cancer in the proportion with higher than average perceived
risk.
Measures. The interview consisted of the following measures used in other surveys of men with prostate cancer:
1. Screening behavior. Men were asked if and when they
had a digital rectal exam (DRE) and a PSA test. These
questions have been asked in studies of prostate screening
by others (6, 37). A recent exam was defined as one that
took place in the year of the interview or the previous
calendar year. Because a PSA test and DRE are often done
in different settings and have different barriers, receipt of
a PSA test and a DRE were treated as separate variables in
the analysis.
2. Knowledge. Men’s knowledge of prostate cancer, including risk factors, symptoms, and the natural history of the
disease, was assessed. The nine items included, ‘‘If you
are having problems urinating, then you probably have
Cancer Epidemiol Biomarkers Prev 2006;15(11). November 2006
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Cancer Epidemiology, Biomarkers & Prevention 2169
Figure 1. Participant recruitment.
3.
4.
5.
6.
7.
prostate cancer;’’ ‘‘If you have a family member who had
prostate cancer, then you are more likely to get prostate
cancer,’’ ‘‘Most men with untreated early-stage prostate
cancer will not die from it.’’ The measure was the number
of correct answers (21).
Sociodemographic information. Participants were asked
their age, years of education, marital status, employment,
and existence and type of health insurance. Self-identified
race/ethnicity was ascertained during eligibility screening.
Family history. Men were asked whether they had a
family history of prostate cancer and, if so, which relatives
had been diagnosed with the disease. Because perceptions
of a family history may be related to actual behavior, selfreport is the appropriate measure. The self-report was
validated by the tumor registry for men whose father or
brother was recruited through the tumor registry.
Social support was measured using the Social Network
Index (22). The index assesses the amount and frequency
of social contacts. The index has been widely used to
explore the social networks in both patient and community samples. It is predictive of initial utilization of cancer
screening services as well as morbidity and mortality in
community samples (23, 24).
Health status was assessed using the MOS SF-12 (25, 26).
These questions have been widely used to determine
levels of functional health in the general population as
well as with cancer patients (25). Measures include
questions on mental health, vitality, physical functioning,
pain, role limitations due to physical health, role
limitations due to emotional problems, social functioning,
and general health. The measures were combined to form
composite measures of physical health and mental health.
The 2-week test-retest correlations for physical and mental
components were 0.89 and 0.76, respectively; the validity
of these scales have been reported elsewhere (26).
Other health-related variables included the presence of
chronic diseases and the number of urinary tract
symptoms. They also reported whether they had seen a
physician for a check-up in the past year.
8. A three-item measure of prostate cancer worries was used
following the work of Lerman et al. (27) for breast cancer
and Bratt et al. (14) for prostate cancer. Each man was
asked how often in the past month (a) he had thought
about his own chances of developing prostate cancer, (b)
had thoughts about his chances of getting prostate cancer
affected his mood, and (c) had thoughts about his chances
of getting prostate cancer affected his ability to perform
his daily activities. The responses to these items (1, not at
all or rarely; 2, sometimes; 3, often; 4, almost all of the
time) were summed to form a scale that was unidimensional and cumulative.
9. A single-item measure of perceived risk of prostate cancer
was used following the work of Lerman et al. (27) and
Bratt et al. (14). Each man was asked if he thought his risk
of prostate cancer compared with the average man of his
age was very much lower than average, somewhat lower
than average, average, somewhat higher than average, or
very much higher than average.
10. Barriers to screening consisted of seven items, including
physical discomfort of a DRE, the cost of the PSA test, and
worry about the PSA blood test results. These items were
adapted to the U.S. health care system from those
developed in the United Kingdom (21); for instance, the
cost of a PSA test was added. Each man was asked to
indicate which of the following might put him off having
prostate exams or tests at his doctor’s office, with each
item rated on a scale from 1 (not difficult at all) to 5 (very
difficult; ref. 21).
Analysis Plan. Descriptive statistics were computed for
study variables, including means and SDs for continuous
variables and frequencies for categorical variables. Because the
comparison of interest for cancer worries was between highly
worried men and others, the scale was dichotomized at the
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2170 Prostate Cancer Screening
highest quartile in the analysis. For perceived risk, the
comparison of interest was between men with higher than
average perceived risk and others. Perceived risk and prostate
cancer worries were treated as binary in the analyses.
Logistic regression was used to create models of perceived
risk (higher than average versus other), prostate cancer worries
(z5 versus <5), corresponding to the highest quartile versus
the lower three quartiles, receipt of DRE (recent versus not
recent or never), and receipt of PSA (recent versus not recent
or never). To ascertain the relationships among self-reported
first-degree family history, perceived risk, worries, and
screening following the posited order of influence, perceived
risk was modeled as a function of family history (yes versus
no); worries as a function of family history and perceived
risk; and DRE and PSA as functions of family history,
perceived risk, worries, and relevant barriers. All models
controlled for sociodemographics, health-related factors, and
knowledge. Sociodemographic factors in the models included
age (continuous), marital status (married/partner versus
single), education (college graduate versus less), employment
(yes versus no), insurance (private versus public/none),
recruitment source (survivor versus organization), and social
network index (continuous). Health-related factors included
check-up in past year (yes versus no), physical well-being
(continuous), mental well-being (continuous), number of
chronic conditions (continuous), and number of urinary tract
symptoms (continuous). Knowledge was treated as a continuous variable. Barriers to both DRE and PSA included cost of
doctor visit (yes versus no), time off work for appointment (yes
versus no), and concern about side effects of prostate cancer
treatment (yes versus no). The DRE-specific barrier was
discomfort of the DRE (yes versus no); and PSA-specific
barriers were worry about PSA results (yes versus no), cost of
PSA test (yes versus no), and finding a blood test upsetting
(yes versus no). A score of 3 to 5 was considered to indicate the
presence of a barrier.
Results
Table 1. Sociodemographics, health-related factors, and
prostate cancer screening characteristics of a sample of
African American men ages 40 to 74 years (n = 208)
Measure
Sociodemographics
Age
Married/partner*
College graduate*
Employed
Private insurance
Referred by survivor
Social network index
Health-related factors
Check-up in past year
Physical well-being (SF12)
Mental well-being (SF12)
No. chronic conditions
No. urinary tract symptoms
Prostate cancer knowledge
Barriers to prostate cancer screening
Cost of doctor visit
Time off work for appointment
Side effects of cancer treatment
Discomfort of DRE
Worry about PSA results
Cost of PSA test
Blood test upsetting
First-degree family history
Perceived risk higher than average
Prostate cancer worries score >4
Prostate cancer screening tests
Ever had DRE
Had DRE in past year
Ever had PSA test
Had PSA test in past year
n (%)
Mean (SD)
NA
(74.0%)
(37.5%)
(64.9%)
(84.5%)
(46.2%)
52.96 (8.45)
NA
NA
NA
NA
NA
2.67 (1.00)
177 (85.1%)
NA
NA
NA
NA
NA
NA
50.69 (8.68)
53.46 (8.40)
1.82 (1.45)
1.33 (1.50)
5.32 (1.58)
154
78
135
174
96
28
39
77
92
40
32
21
88
63
56
(13.5%)
(18.8%)
(37.0%)
(44.2%)
(19.2%)
(15.4%)
(10.1%)
(42.3%)
(30.3%)
(26.9%)
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
164
116
132
102
(78.8%)
(55.8%)
(63.5%)
(49.0%)
NA
NA
NA
NA
*Yes versus no.
with a family history were more likely to get a PSA test (OR,
3.03; 95% CI, 1.13-8.10). Other factors that predicted getting a
PSA test included having higher than average perceived risk
(OR, 2.56; 95% CI, 1.11-5.91), age (OR, 1.10 per year; 95% CI,
1.04-1.16), having a check-up in the past year (OR, 5.62; 95% CI,
1.53-20.7), and worry about PSA test results (OR, 3.46; 95%
CI, 1.12-10.7), and negatively associated with concerns about
the cost of a doctor visit (OR, 0.04; 95% CI, 0.003-0.54; Table 2).
Contrary to predictions, a family history did not predict
having a recent DRE. Men were more likely to have had a
recent DRE if they were older (OR, 1.05 per year of age; 95% CI,
1.00-1.11) or had a check-up in the past year (OR, 3.38; 95% CI,
1.21-9.44) and less likely if they reported more urinary tract
symptoms (OR, 0.75 per symptom; 95% CI, 0.59-0.95) or were
concerned about the physical discomfort of the exam (OR, 0.50;
95% CI, 0.20-0.99; Table 2). Thus, both family history and
perceived risk of prostate cancer were independently associated with the receipt of a recent PSA test, but not a DRE.
Characteristics of the Sample. The average age of the
sample was 53 years; the majority were married or partnered
and employed (Table 1). The sample was also well educated
with 38% being college graduates. With regard to their medical
care, most had private insurance and had been to see a
physician for a check-up in the past year. Among men
recruited from cancer cases, 42% reported having a firstdegree relative with prostate cancer, whereas 17% of men
recruited from community samples reported having one.
Nearly one third of these men perceived their risk as higher
than average. Their average knowledge score was f60%
correct (5.32 of 9). The most common potential barriers to
cancer screening were the discomfort of a DRE and concerns
about the side effects of cancer treatment, followed by worry
about PSA results and taking time off work to keep a doctor’s
appointment. Over half the men had a DRE in the past year
and approximately half had a PSA in the past year.
Discussion
Regression Analyses. Contrary to predictions, men with a
family history did not perceive their risk to be higher than
those without a family history. Men were more likely to
perceive their risk as higher than average if they were younger
[OR, 0.95 per year of age; 95% confidence interval (95% CI),
0.90-0.99] or a college graduate (OR, 2.76; 95% CI, 1.34-5.67),
and less likely if they had better mental well-being (OR, 0.95
per unit of scale; 95%CI, 0.92-0.99). Contrary to predictions,
men with a family history were no more likely to worry more
about their chances of getting prostate cancer than those
without a family history. However, men who perceived their
risk to be higher also reported more prostate cancer worries
(OR, 3.70; 95% CI, 1.72-7.96). Consistent with predictions, men
Screening aims to detect disease at an earlier stage when there
are better options for treatment and a better opportunity to
reduce morbidity and mortality (28). However, screening for
prostate cancer remains controversial. First, the two major
screening methods—DRE and PSA test—have low predictive
values (21-55% for the DRE and 32-49% for the PSA test;
refs. 28-31) and neither test has high sensitivity (72.1% and
53.2%, respectively; ref. 32). Some believe that the increasing
PSA level is the most informative (33). Second, there are no
completed randomized studies that show that screening
reduces morbidity or mortality (34). There is a lack of
consensus among agencies that develop screening guidelines
(34, 35). Finally, the treatment for early prostate cancer is not
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Cancer Epidemiology, Biomarkers & Prevention 2171
without its own set of complications, including impotence,
urinary incontinence, and gastrorectal problems (36).
The major hypotheses tested were that men with a firstdegree family history of prostate cancer perceive their risk to
be higher, are more worried about getting prostate cancer, and
are more likely to have recently used early detection methods
than men without such history.
The results do not support the hypothesis that family history
is associated with increased perceived risk. Rather, younger,
better-educated men and men with poorer mental health
perceived themselves to be at increased risk. Our findings are
consistent with the findings from the 1992 National Prostate
Awareness week findings that 41% of African American men
interviewed knew that heredity could increase their risk,
whereas 53% were aware that race was a risk factor (9), and the
Behavioral Risk Factor Survey findings in New York (12) that
older men and those with less education were more likely to
perceive that they were at no risk. They also suggest that
awareness of risk factors for prostate cancer may not have
increased among older and less educated men. The relationship between mental health and perceived risk has been found
in other studies as well (37).
The results do not support the hypothesis that family history
is associated with greater worries about getting prostate
cancer. Perceiving oneself at risk was significantly associated
with prostate cancer worries. It is not unexpected that
individuals who were at higher perceived risk reported greater
cancer worries. Although this finding is consistent with the
literature, it has not been documented with regard to African
American men (14). Although having a first-degree relative
increases one’s risk of the disease by an OR of 2.5 (6), the
perception of being at higher than average risk (OR, 3.7) was
more strongly associated with concerns about getting prostate
cancer than was family history (OR, 2.3). These findings
suggest that although awareness of the importance of heredity
on risk is not salient in this group of men, perceived risk is, and
this is the factor driving cancer worries.
The results support the hypothesis that family history is
associated with the use of the early-detection method that is
specific to prostate cancer, PSA testing. This is consistent with
the literature which has found that screening intentions of men
informed about the benefits of screening as well as the efficacy
of PSA screening have been associated with family history,
younger age, as well as uniformed older men (17-19).
However, there was no relationship between family history
and having had a digital rectal exam. We did find that the
discomfort of the DRE exam was reported as a barrier. If the
man finds the DRE procedure uncomfortable, he may be less
likely to agree to the exam when his symptoms previously
have been related to a chronic condition, such as benign
prostate hypertrophy. A negative attitude to the DRE does not
seem to deter some men from prostate cancer screening. A
study of 13,500 healthy men undergoing PSA-only screening
found that 78% would participate in a screening that included
both DRE and PSA. African American men (34% of the sample)
were the most willing to participate in a PSA plus DRE
screening (84%; ref. 38) and, in another study, 77% reported
that they would follow-up abnormal results (39). In our current
study, being older was associated with having had a recent
DRE or a recent PSA test. Men who had seen a physician for a
health check-up were also more likely to have had a recent
DRE or PSA test.
Education also was associated with prostate cancer knowledge (not shown). The relationship between age and education
and knowledge of risk factors such as being African American
is not surprising, suggesting that younger, better-educated
men are more widely read and, therefore, more aware of their
risk. It is not surprising that knowledge by itself did not have a
direct effect on risk perception because intervention to increase
knowledge often result in a reduction of one’s intention to be
screened (39). This may be an age or period effect as prostate
cancer was not widely publicized 10 years ago.
However, the number of nonspecific urinary tract symptoms was negatively associated with screening, because
chronic symptoms with negative test results were not
perceived as requiring further exams. The cost of a doctor’s
visit was a deterrent for having a PSA in the past year, whereas
worry about the results was not. Cost has been considered an
Table 2. Relationship between family history of prostate cancer, perceived risk, prostate cancer worries, and receipt of
DRE and PSA test among African American men ages 40 to 74 years (n = 205)
Independent variables
Sociodemographics
Age at pretest
Married/partner
College graduate
Employed
Private insurance
Referred by survivor
Social network index
Health-related factors
Check-up in past year
Physical well-being
Mental well-being
No. chronic conditions
No. urinary tract symptoms
Prostate cancer knowledge
Barriers to screening
Cost of doctor visit
Time off work for appointment
Side effects of treatment
Discomfort of DRE
Worry about PSA results
Cost of PSA test
Blood test upsetting
First-degree family history
Perceived risk > average
c
Prostate cancer worries
Perceived risk higher
than average, OR (95% CI)*
Prostate cancer worries,
OR (95% CI)*
c
Had DRE in past year,
OR (95% CI)*
Had PSA test in
past year, OR (95% CI)*
0.95
1.15
2.76
0.89
0.89
1.35
1.00
(0.90-0.99)
(0.51-2.61)
(1.34-5.67)
(0.37-2.12)
(0.32-2.50)
(0.59-3.08)
(0.69-1.45)
0.98
0.58
0.75
1.42
1.43
0.40
0.73
(0.93-1.04)
(0.25-1.35)
(0.33-1.74)
(0.53-3.82)
(0.48-4.23)
(0.15-1.07)
(0.47-1.12)
1.05
1.17
2.05
1.02
1.51
0.68
1.18
(1.00-1.11)
(0.52-2.63)
(0.99-4.27)
(0.40-2.56)
(0.51-4.47)
(0.29-1.56)
(0.82-1.69)
1.10
0.99
1.37
0.42
0.39
0.45
1.45
(1.04-1.16)
(0.37-2.63)
(0.62-3.05)
(0.15-1.20)
(0.10-1.57)
(0.17-1.19)
(0.96-2.20)
1.28
1.00
0.95
1.30
0.99
1.13
(0.49-3.36)
(0.95-1.04)
(0.92-0.99)
(0.99-1.70)
(0.79-1.25)
(0.91-1.40)
0.68
0.96
0.96
1.17
1.07
0.97
(0.25-1.85)
(0.91-1.01)
(0.92-1.00)
(0.87-1.58)
(0.84-1.37)
(0.76-1.23)
3.38
0.97
0.97
1.01
0.75
1.04
(1.21-9.44)
(0.93-1.02)
(0.93-1.01)
(0.77-1.32)
(0.59-0.95)
(0.84-1.30)
5.62
1.03
0.97
1.08
0.80
1.26
(1.53-20.7)
(0.98-1.08)
(0.93-1.02)
(0.78-1.48)
(0.61-1.05)
(0.98-1.64)
NA
NA
NA
NA
NA
NA
NA
2.31 (0.89-6.01)
3.70 (1.72-7.96)
NA
0.60
1.15
0.76
0.50
NA
NA
NA
NA
NA
NA
NA
1.21 (0.54-2.76)
NA
NA
(0.18-2.00)
(0.46-2.86)
(0.37-1.56)
(0.26-0.99)
NA
NA
NA
1.49 (0.64-3.46)
0.91 (0.43-1.90)
0.93 (0.43-2.05)
0.04 (0.003-0.54)
1.64 (0.58-4.66)
0.72 (0.30-1.73)
3.46
1.23
2.47
3.03
2.56
0.56
(1.12-10.7)
(0.15-10.4)
(0.57-10.8)
(1.13-8.10)
(1.11-5.91)
(0.23-1.34)
*Odds Ratio (OR) and 95% CI adjusted for all covariates in model.
cHighest quartile.
Cancer Epidemiol Biomarkers Prev 2006;15(11). November 2006
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2172 Prostate Cancer Screening
access barrier to screening for cancer and other chronic
illnesses (40). These data provide additional support for cost
as a barrier to access. Contrary to the literature, neither
prostate cancer knowledge nor prostate cancer worries were
related to screening behavior (9, 14). However, worry about
the test results was positively associated with having a recent
PSA test, very likely because a portion of men who had been
recently tested were being monitored because of elevated PSA
levels.
Men’s knowledge of their family history was sometimes
imperfect. For example, two brothers who had prostate cancer
each referred the other to the study as a cancer-free individual.
Eleven men known to have a family history of prostate cancer
were unaware of the fact and, in this analysis were classified as
having no family history of the disease. As described earlier, to
protect the confidentiality of the index cases, participants were
not given the names of the persons who had referred them.
There are some limitations to the study as well. Participants
were highly educated with 37.5% having a college education.
This compares favorably to African American men living in
California. Based on the 2003 California Health Interview
Survey, 30.8% of African American men ages 40 to 74 years are
college graduates (41). There are some differences in education
by recruitment source. Among case referrals, 32% had a high
school diploma or less and 31% were college graduates; among
organizational referrals, 16% had a high school diploma or less
and 43% were college graduates. Thus, the registry referrals
were similar in educational attainment to the general population of African American men in California. But those recruited
through community organizations had substantially higher
levels of education. Thus, this limits the ability to generalize
the study results to all African American men ages 40 to
74 years.
A second possible limitation is also based on the method of
recruitment. Most of the men with a first-degree family history
of prostate cancer were recruited through a father or brother
whose cancer was reported to the registry, whereas most of the
men without a family history of the disease were recruited
through church groups and other organizations. Given the
difference in recruitment sources, it is not surprising that
men without a family history had significantly larger
social networks than did the relatives of cancer survivors
(P = 0.0002). Thus, men without a family history may have had
more access to information about PSA testing through their
network of friends and relatives (23). However, the analysis
controlled for social network size and found that family
history increased the odds of having a PSA test in the past year
3-fold.
The importance of this study lies in its finding that family
history and perceived risk were both independently associated
with having a recent PSA test in African Americans. In contrast
to others (16), perceived risk does not mediate the relationship
between family history and screening. It is possible that
physicians were more likely to refer men with a family history
of prostate cancer for PSA testing, whereas men with higher
perceived risk initiated screening themselves. Because a
medical visit provides the opportunity for the physician to
recommend or the patient to request a PSA test, the path to
screening is through one’s physician.
benefits. Men who have had a recent physical exam are more
likely to report having a PSA or DRE. Thus, having a recent
check-up is the pathway to screening. However, the cost of the
doctor visit may reduce access to screening among African
American men.
Acknowledgments
We thank the following people at the Northern California Cancer
Center: Merrilee Morrow, data manager; Lynette Evans, coordinator;
Rose Marie Colbert, Lorraine Lindow, Julie Scholz, and Wayne Jeffcoat,
interviewers.
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Cancer
Epidemiology,
Biomarkers
& Prevention
Correction
Correction: Family History, Perceived Risk,
and Prostate Cancer Screening among
African American Men
In this article (Cancer Epidemiol Biomarkers Prev 2006;15:2167–73), which
was published in the November 2006 issue of Cancer Epidemiology, Biomarkers
& Prevention (1), an author’s name was printed in the byline incorrectly as
Ingrid Oakley-Girvans. The author’s name is Ingrid Oakley-Girvan.
Reference
1. Bloom JR, Stewart SL, Oakley-Girvan I, Banks PJ, Chang S. Family history, perceived risk, and
prostate cancer screening among African American men. Cancer Epidemiol Biomarkers Prev
2006;15:2167–73.
Published OnlineFirst December 16, 2011.
doi: 10.1158/1055-9965.EPI-11-1118
Ó2011 American Association for Cancer Research.
388
Cancer Epidemiol Biomarkers Prev; 21(2) February 2012