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PROSTATE SCREENING EDUCATION FOR
PRIMARY CARE PROVIDERS

By

Opal Patricia Lesse

Scholarly Project

Submitted to
Michigan State University
in partial fulfillment for the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

2000

ABSTRACT

PROSTATE SCREENING EDUCATION FOR
PRIMARY CARE PROVIDERS

By

Opal Patricia Lesse

Prostate cancer is now the most commonly diagnosed cancer in men in the United
States. It is projected that there will be 179,300 new cases of prostate cancer diagnosed
this year, and 37,000 prostate-related cancer deaths will occur (National Cancer Institute,
1999). The problem is that few men are aware of the risk factors that may lead to
prostate cancer. Men are not aware of the risk factors of age, family history, and race that
are key indicators for an earlier prostate screening exam by the age of 40 for African-
American men, and for all other men at age 50.

The purpose of this project is to provide information about prostate screening for
the primary care providers and their support staff, so that every man may be screened.

The theoretical background of the health promotion model will be used.

Copyright by
OPAL PATRICIA LESSE
2000

iii

ACKNOWLEDGMENTS

The author expresses gratitude to Professors George Allen, Kathy Dontje, and
Laura Struble for their guidance, wisdom and patience. They provided support, time and
humor, when needed, to get through life. The author especially wants to thank all of her
children, Amber, Julian, David, Michael, and Aaron, for making all of the research
worthwhile. Their love and belief in “living dreams” is the reason this project is
completed. Thank you, Karl W. Scott III and Reverend Walter MacDonald for being

available to encourage me with your gentle guidance.

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................ vii
LIST OF FIGURES ......................................................................................................... viii
CHAPTER ONE
INTRODUCTION ............................................................................................................... 1
CHAPTER TWO
CONCEPTUAL MODEL .................................................................................................... 4
Prior Related Behaviors ................................................................................................. 6
Personal Factors ............................................................................................................. 7
Behavior-Specific Cognitions and Affect ...................................................................... 7
Perceived Barriers to Action .......................................................................................... 8
Perceived Self-Efficacy ................................................................................................. 9
Activity-Related Affect ................................................................................................ 10
Interpersonal Influences ............................................................................................... 11
Situational Influences ................................................................................................... 11
Behavioral Outcome .................................................................................................... l2
Health-Promoting Behavior ......................................................................................... 12
CHAPTER THREE
LITERATURE REVIEW .................................................................................................. 14
Risk Factors ................................................................................................................. 14
Screening Measures ..................................................................................................... 15
Digital Rectal Exam ............................................................................................... 15
Prostate-specific Antigen ....................................................................................... 16
Imaging Procedures ............................................................................................... 19
Prostate Cancer History ............................................................................................... 20
Age ......................................................................................................................... 20
Race/Genetics ........................................................................................................ 21
Other Biological Characteristics ............................................................................ 22
Personal Health Habits ........................................................................................... 23
Environmental ........................................................................................................ 23

CHAPTER FOUR

METHODS ........................................................................................................................ 26
Prostate Screening for Health Care Providers ............................................................. 26
Prostate Screening for the Public ................................................................................. 27
Evaluation of the Project .............................................................................................. 28

CHAPTER FIVE

NURSING IMPLICATIONS ............................................................................................. 29
Conclusion ................................................................................................................... 31

REFERENCES .................................................................................................................. 32

TABLES ............................................................................................................................ 39

FIGURES ........................................................................................................................... 40

APPENDIX A
Cover Letter for Primary Care Practitioners ................................................................ 42

APPENDIX B
Prostate Cancer Facts ................................................................................................... 43
Prostate Cancer Incidence Rate ................................................................................... 44
Prostate Cancer Mortality ............................................................................................ 45

APPENDIX C
Prostate Cancer Screening ................ ' ........................................................................... 46

vi

LIST OF TABLES

Table 1 - PSA Reference Ranges Comparison by Age and Race
(Moyad & Oesterling, 1997) .............................................................................................. 39

vii

LIST OF FIGURES

Figure 1 — Pender’s Revised Health Promotion Model ..................................................... 40

Figure 2 — Lesse’s Modified Revised HPM ....................................................................... 41

viii

CHAPTER ONE

Introduction

Prostate cancer currently is the most common cancer diagnosed in men in the
United States (Carter & Coffey, 1990). The National Cancer Institute (N CI) estimates
that 179,300 new cases of prostate cancer will be diagnosed this year, and 37,000 prostate
cancer-related deaths will occur (NCI, 1999). Epidemiological and screening studies
performed over the past several decades have raised several important questions about the
pathogenesis of the disease, but a definite cause for prostate cancer has not been
established (Pienta & Esper, 1993). Age-adjusted incidence rates, as well as death rates
from prostate cancer, vary dramatically from country to country, even if one allows for
the difference in availability of screening programs (Pienta et al., 1989).

Screening for cancer is an examination (or testing) of people for early stages in
the development of cancer even though they have no symptoms. Scientists have studied
patterns of cancer in the population to learn which people are more likely to contract
certain types of cancer. This information sometimes will help the healthcare professional
recommend who should be screened for certain types of cancer, what types of screening
tests people should have, and how often these tests should be performed (N C1, 1999).

Even though there are screening measures for prostate cancer, there are two major
problems with the way that they are currently implemented. First is the specificity and

sensitivity of the tools, and second is the primary care provider using the tools available

for appropriate screening. For example, the digital rectal exam (DRE) is recommended
for all men 50 years and older (NCI, 1999). In this exam, the prostate is felt for
enlargement and firmness; however, the prostate can feel normal and still be infiltrated
with the first stages of cancer. The NCI (1999) recommends that prostate-specific
antigen (PSA) be tested in African-American men at age 40, and all other men at age 50.

The purpose of this project was to develop an educational, primary care, health
promotion document for healthcare providers. There are two populations that might be
targeted by this education, namely primary caregivers and male patients ages 40 to 50
and older. Although both populations would benefit, primary caregivers are currently in
the position of improving the screening procedures. Although primary caregivers are
likely to know the risk factors, education about screening has not been an area that has
been focused on at this time. In addition, the risk factors of age, family history, and race
tend not to be addressed by healthcare providers until a problem develops (Roberts et al.,
1994)

Prostate screening assessment is the responsibility of the primary caregiver, yet it
is not being done. Catalona (1999) states, “At least 47 percent of men ages 40-59 have
never heard of a PSA test. An amazing 60% of men between the ages of 40 and 59 say
their doctors have never talked about the PSA test, 43% of men over 50 have never had
the test, and of men over 40 with a family history of prostate cancer, 35% have never
been tested and their doctors have never discussed the PSA test.”

Men under age 50 are not aware of their risk factors. The majority of men are not
seeking screening for prostate cancer until their symptoms reach such a severe state that

they need an invasive approach (Roberts et al., 1994). Men need to have their health

3

history and risk factors clearly defined for them with each physical exam, in the media, in
office waiting areas, and through screening programs within the community. If men at 40
years of age felt the importance of knowing the risk factors for prostate cancer and how
to get the screening they need, cancer-related deaths of men over 50 would decrease
(Roberts et al., 1994).

Prostate cancer is the most common cancer diagnosed in men in the United States.
The two screening tools for prostate cancer are the DRE and the PSA test. The NCI
recommends that the DRE and PSA test be performed annually on all men age 50 and
older. All African-American men, and men with a family history of cancer, should begin
their screening at age 40 with a DRE and a PSA test. The primary care giver needs to
educate the patient and the public about the screening procedures for prostate cancer,
either with physical exam questions/answers or with written infonnation/lectures.

Due to the need for more screening to be done in the male population, a cover
letter was created (Appendix A), along with a prostate cancer fact sheet (Appendix B)
and a lecture outline aimed at healthcare professionals and their support staff (Appendix
A). This information can be presented at community clinics and health maintenance
organizations (HMOs), sent to the media, and used for publication (Appendix B). The

ultimate goal is that more men be screened for prostate cancer (Appendix C).

CHAPTER TWO

Conceptual Model

According to Pender (1997), the revised health promotion model (HPM) can be
used as a framework for research aimed at predicting overall health-promoting lifestyles
as well as specific behaviors. Assessment of the individual client in the context of health
promotion expands beyond physical assessment to also include a comprehensive
examination of other client health parameters, health beliefs, and health behaviors. The
components of health assessment focusing on individual clients are (1) functional health
patterns, (2) physical fitness evaluation, (3) health risk appraisal, (4) life stress review,
(5) spiritual assessment, (6) social support systems review, (7) health beliefs review, and
(8) lifestyle assessment. This paper concentrates on the primary care provider, reviewing
educational and community-based programs with a focus on interpersonal influences and
situational influences using the I-IPM by Pender (Figure 1).

The following are the I-IPM concepts (Pender, 1997):

. Persons, in all their bio-psychological complexity, interact with the environment,
progressively transforming the environment and being transformed over time.

. Health professionals constitute a part of the interpersonal environment, which exerts

influence on persons throughout their life span.

. Self-initiated reconfiguration of persons-environment interactive patterns is essential
to behavior change. Persons seek to create conditions of living through which they
can express their unique human health potential.

. Persons have the capacity for reflective self-awareness, including assessment of their
own competencies.

. Persons value growth in directions viewed as positive, and attempt to achieve a
personally acceptable balance between change and stability.

. Individuals seek to actively regulate their own behavior.

The HPM has three variables related to healthcare behavior: (1) individual
characteristics and experiences, (2) behavior-specific cognitions, and (3) behavioral
outcomes. Empirical studies indicate that often the best predictor of behavior is the
fi'equency of the same or similar behavior in the past. Prior behavior is proposed as
having both direct and indirect effects on the likelihood of engaging in health-promoting
behaviors. In the modified HPM, the shaded lines represent the behaviors and actions by
the healthcare professional and the client (Figure 2.)

Prostate exams should be viewed in a similar algorithm as the mammogram. As
the woman ages, her risk factor goes up, especially with a family history of cancer. The
risk for prostate cancer increases with age, and family history as well. In Pender’s HPM,
health-promoting education from the professional caregiver is stressed to guide and
counsel the patient toward optimal health. The prostate exam should be built into the

physical exam the same as a breast exam on a yearly basis (Pender, 1997).

Prior Related Behaviors

Consistent with social cognitive theory, prior behavior is proposed as also having
an indirect influence on health-promoting behavior through perceptions of self-efficacy,
benefits, barriers, and activity-related effects. The prior related behavior would be
assessed with the screening for prostate cancer in an office visit. According to Bandura,
actual enactment of a behavior and its associated feedback are major sources of efficacy
or “skill” information. Anticipated or experienced benefits from engaging in the
behavior are referred to by Bandura as outcome expectations (Pender, 1997). If desired
short-term benefits are experienced early in the course of the behavior, the behavior is
more likely to be repeated. Barriers to a given behavior are experienced and stored in
memory as “hurdles” that need to be overcome to successfully engage in the behavior.
The memory can be positive or negative, and the healthcare provider can help the client
shape a positive behavioral history for the future by focusing on the benefits of a
behavior, teaching clients how to overcome hurdles, and engendering high levels of
efficacy and positive effects through successful experiences of performance and positive
feedback (Pender, 1997). Educating patients to be responsible for their health and well-
being is a large part of changing health behaviors. Men should expect a DRE at age 50,
or at age 40 if they are African-American or if they have a high-risk status due to a
history of cancer in the family. Assisting a patient to understand the importance of a
DRE or PSA test as part of the physical exam is just as important as screening for
cholesterol. It should be pointed out to the patient that overcoming the hurdle of dreading
a DRE is one step toward shaping a positive example for those around him. The DRE is

a personal experience that some men will avoid due to embarrassment or dread of

knowing the results of such a test. Explaining to the man examples of women that have
talked about such exams (such as vaginal and breast exams) has increased the screening
for cancer in women. If men know which screening tests are available and the way they
are accurately done, this hurdle of avoiding prostate exams or blood work may be
overcome.
Personal Factors

The relevant personal factors predictive of a given behavior are shaped by the
nature of the target behavior being considered. The targeted behavior is to educate men
about their risk factors and to have them act upon their knowledge base for disease
prevention. In the HPM, personal factors have been categorized as biological,
psychological, and socio-cultural. Biological factors include age, gender, perceived
health status, race, and ethnicity. Personal psychological factors can include such
variables as self-esteem, motivation, personal competence, perceived health status, and
definition of health. Socio-cultural factors include race, ethnicity, acculturation,
education, and socio-economic status (Pender, 1997). The prostate cancer risk is highest
among African-American men due to their ethnicity (Moyad & Oesterling, 1997).
Behavior-Specific Cognitions and Affect

A person’s decision to engage in a particular behavior often hinges on the
anticipated benefits or outcomes that will occur. Anticipated benefits of action are
mental representations of the positive or reinforcing consequences of a behavior. Beliefs
in benefits or positive outcome expectations have generally been shown to be a
necessary, although not a sufficient, condition for engagement in a specific health

behavior. Individuals tend to invest time and resources in activities with a high

likelihood of increasing their experience of positive outcomes. The motivational
importance of perceived benefits of action has been supported in the majority of HPM
studies in which it has been tested (Pender, 1997). Prostate screening for cancer should
be marketed similarly to the mammogram, Pap screening, and cardiac risk assessments.
The use of Pap tests and mammograms as screening tools have saved many women; the
same could be said for the DRE and PSA tests if men were to take advantage of them.
Perceived Barriers to Action

According to Pender (1997), anticipated barriers have been repeatedly shown in
empirical studies to affect intentions to engage in a particular behavior and the actual
execution of the behavior. In relation to health-promoting behaviors, barriers may be real
or imagined. They consist of personal perceptions concerning the expense,
inconvenience, or time-consuming nature of a particular action. Barriers are often
viewed as the blocks or hurdles and personal costs of undertaking a given behavior.
Barriers usually arouse motives of avoidance in relation to a given behavior (Pender,
1997). Men often avoid prostate exams due to the embarrassment and uncomfortable
procedure of having their rectum examined. A barrier could be fear of disease and its
consequences, such as treatment and possible side effects of treatment.

A barrier for the healthcare professional could be the busy office schedule or the
lack of training within the support staff to educate or examine men for prostate cancer.
The office environment can constitute a barrier as well if there is no literature about .
prostate screening available for clients to read. Also the many different views on prostate
cancer screening can be confusing. The healthcare professional should choose one

guideline to follow and use this protocol to guide the practice of prostate screening.

Barriers for many men may be access to care, cost, and inconvenience due to
time. Decreasing barriers for screening would include access to free screening, brochures
with information that the lay public understands, and assisting the client with healthcare
decisions regarding his environment and lifestyle. An example would be to offer a free
“prostate screening” day in the primary caregiver’s office. This would be a door of
opportunity to screen men for their risk factors regarding prostate cancer.

According to Pender (1997), when readiness to act is low and barriers are high,
action is unlikely to occur. When readiness to act is high and barriers are low, the
probability of action is much greater. Perceived barriers to action are depicted in the
HPM as affecting health-promoting behavior both directly, by serving as blocks to action,
as well as indirectly through decreasing commitment to a plan of action (Pender, 1997).
The perfect opportunity is when the man is in his healthcare provider’s office for a visit;
this is an opportunity to schedule an exam, or, especially if the man falls into a high-risk
category, to do one right then.

Perceived Self-Efficacy

The judgment of personal capability to organize and execute a particular course of
action is self-efficacy. This feature is not concerned with the skill one has, but rather
with judgments of what one can do with whatever skill one possesses. Judgments of
personal efficacy are distinguished from outcome expectations: perceived self-efficacy is
a judgment of one’s own abilities to accomplish a certain level of performance, whereas
an outcome expectation is a judgment of the likely benefits (e.g., cost benefits) such
behavior will produce. Personal knowledge about one’s self-efficacy is based on four

types of information: (1) performance attainments from actually engaging in the

IO

behavior, and evaluation of that performance in relation to some self-standard or external
feedback given by others, (2) vicarious experiences of observing the performance of
others and the related self-evaluation and feedback, (3) verbal persuasion on the part of
others that one does possess the ability to carry out a particular course of action, and (4)
physiologic states (e.g., anxiety, fear, calm, tranquility) from which people judge their
competencies. The more positive the effect, the greater the feeling of efficacy. Self-
efficacy is proposed as influencing perceived barriers to action, with higher efficacy
resulting in lowered perception of barriers to the performance of the target behavior.
Self-efficacy motivates health-promoting behavior directly by efficacy expectations, and
indirectly by affecting perceived barriers and commitment or persistence in pursuing a
plan of action (Pender, 1997). Once a man has read the material given to him (either in
the office or through the mail) about prostate screening, and understands the risk factors
for prostate cancer, a follow-up phone call or letter from the healthcare provider’s office
within two weeks to answer any questions might prompt an exam.
Activity-Related Affect

Activity-related affect is a subjective feeling state that occurs prior to, during, and
following a behavior. This can be positive or negative depending on the feeling and
experience perceived. Thus, activity-related affect is proposed as influencing health
behavior directly as well as indirectly through self-efficacy and commitment to a plan of
action (Pender, 1997). An example may be a 40-year-old male receiving a prostate
brochure from his healthcare provider, scheduling a DRE, and consulting the healthcare

provider about risk factors in order to develop a health promotion plan.

11

The support staff in the healthcare professional’s office can give the client a
brochure about prostate cancer screening, answer any questions the client might have,
and prep the room for the procedure before the healthcare professional enters to examine
the client. The office environment offers a professional accountability and feeling of
knowledge perceived by the patient.

Interpersonal Influences

Interpersonal influences are cognitions concerning the behaviors. beliefs, or
attitudes of others. These cognitions may or may not correspond with reality. Primary
sources of interpersonal influences on health-promoting behaviors are families, peers, and
healthcare providers. Interpersonal influences include norms, social support, and
modeling (Pender, 1997).

Situational Influences

In Pender’s (1997) HPM, situational influences have been re-conceptualized as
direct or indirect influences on health behavior. The patient must have the motivation
and the will to change lifestyle behaviors (Pender, 1997). For example, a prostate exam
is embarrassing and uncomfortable for some men (similar to the mammogram and Pap
exam for women), but the benefits outweigh the uncomfortable procedure. If a man is
aware of the non-preventable risk factors, such as age, race and familial predisposition
for prostate cancer, then he can actively choose a healthier lifestyle to potentially increase
his life span for the quality of life he has chosen.

As mentioned previously, the environment in the healthcare professional’s office

will influence a positive or negative response from the patient. The latest information

12

about prostate cancer screening should be made available to the healthcare provider and
the support staff so they can better inform their patients.
Behavioral Outcome

According to Pender (1997), positive behavioral outcome is the goal for the HPM.
Commitment to a plan of action initiates the behavioral event. The underlying cognitive
process is a commitment to carry out a specific action at a given time and place, with
specified persons or alone, irrespective of competing preferences, and to identify
definitive strategies for eliciting, carrying out, and reinforcing the behavior. For an
optimal outcome measurement, positive or negative, the patient must know risk factors,
options, and potential treatment plans (Pender, 1997). The best practice concerning
prostate cancer is knowledge-based decisions with support from a well-informed,
professional, integrated treatment team.

Health-Promoting Behavior

Health-promoting behavior is the end point or action outcome in the HPM.
Health-promoting behaviors, particularly when integrated into a healthy lifestyle that
pervades all aspects of living, result in a positive health experience throughout the life
span (Pender, 1997).

Screening lies at the heart of health-promoting behavior and quality-of-life issues.
Simply stated, if a man has correct prostate screening early, and has well-informed
information to make decisions regarding treatment options, his quality of life over the
years will be improved. Important quality-of-life issues for men with prostate cancer

include (but are not limited to): immediate or long-term impotence, urinary symptoms

13

(including incontinence), degraded bowel function and pain, altered social function, and
treatment-associated risks (Catalona et al., 1998).

In summary, the HPM has been refined to focus on determinants of behavior.
Where there is already evidence supporting the predictive validity of constructs in the
HPM, such as perceived barriers to action, perceived benefits to action, perceived self-
efficacy, interpersonal influences, and situational influences, health promotion
intervention studies should be designed to incorporate these variables (Pender, 1997).

Fender’s HPM emphasizes the education of patients about risk factors affecting
their health and targets ways to assist patients in changing their healthcare behaviors.
One can improve this process by knowing the cultural environment of the community, by
offering lectures to educate healthcare professionals and their support staff, by presenting
the latest screening procedures to HMOs, by offering free prostate cancer screening for
the uninsured, and by talking to patients about prostate cancer screening.

In summary, the HPM is a theoretical model that is outcome-based, that assesses
all aspects of healthcare behaviors, and that emphasizes health promotion and disease
prevention. The role of the professional caregiver to educate, to overcome barriers, and
to assess cost and access to care is an ongoing part of screening all patients for care. The
professional caregiver must know the latest in research, education, and screening
measures for all disease states. The best way to make a difference in health care for men

is to start with prostate screening using the DRE and PSA test.

CHAPTER THREE

Literature Review

This review of literature is organized to (a) identify risk factors for prostate
cancer, (b) verify that prostate cancer screening is not being done, and (c) identify
possible benefits to early screening. The review of the literature is designed to correlate
with the HPM.

A healthy prostate is defined as a prostate with PSA within normal range for age,
a negative DRE, and no other urinary symptoms. Testing of PSA is the most reliable
method for detecting prostate cancer. In men under age 40, PSA is not normally present
in the blood stream in large amounts; however, because the prostate gland enlarges with
age, it produces more PSA, and it is normal for older men to have slightly more of it in
their circulation. Age-specific references have increased the detection of prostate cancer
in men, making PSA a more accurate andclinically significant test for diagnosing
prostate cancer (Moyad & Oesterling, 1997; Table 1).

Risk Factors

If early detection proves to be clinically beneficial, the following groups are more

likely to benefit: high-risk men, such as Afiican-American men between the ages of 40 to

75 with a life expectancy of more than 10 years and men with a family history of prostate

14

15

cancer between the ages of 40 and 75 with a life expectancy of more than 10 years; and
all other men between the ages of 50 and 75 with a life expectancy of more than 10 years.
The dilemma for men and their healthcare providers is that screening, treatment, failure
to screen, and failure to treat each may have negative consequences for the individual
(Roberts et al., 1994).

As reported by the NCI, possible screening consists of a DRE to determine the
size of the prostate and a PSA test to rule out prostate cancer. Roberts et a1. (1994) state
that there is criticism of the current guidelines that begin with men over 50. They also
relate that some healthcare providers argue that the guidelines are limited because they
are only intended for men over age 50 with classic symptoms of prostatism but no other
severe or confounding medical morbidities. Men need education about screening, and
about the factors of age, family history, and race to determine whether they are at risk for
prostate cancer (Roberts et al., 1994).

The effect of prostate cancer is growing. The advent of newer screening
procedures, such as the PSA test, and growing public awareness have raised questions
concerning the cause of prostate cancer as well as ways to screen and prevent this
disease. The ultimate goal of epidemiological studies is to identify risk factors to guide
disease prevention strategies (Moyad & Oesterling, 1997).

Screening Measures
Digital Rectal Examination

Prior to the 1990’s, the DRE was the test traditionally mentioned for prostate

cancer screening. Although the DRE has been used for many years, careful evaluation of

its efficacy has yet to take place (Gilbertson, 1971). In 1994, Chodak et al. reported on

16

811 unselected patients from 50 to 80 years of age that underwent rectal examinations
and follow-up. Thirty-eight of 43 patients with a palpable abnormality in the prostate
agreed to undergo biopsy. The positive predictive value of a palpable nodule (i.e., how
many actually were prostate cancer) on biopsy was 29 percent (1 1 out of 38) (Chodak et
al., 1994). In contrast, Wajsman and Chu (1987) have reported that even with rectal
examination, only 20 percent of cases are localized at diagnosis.

The sensitivity of the test indicates how likely it is that a case of prostate cancer
will screen as positive, whereas specificity indicates how likely it is that someone without
prostate cancer will screen as negative. Higher sensitivity and specificity thus indicate
higher accuracy, and therefore greater believability.

The NCI’s (1999) data on the DRE for detection of prostate cancer has been
summarized as follows:
0 Sensitivity—55-69 percent
0 Specificity—89-97 percent
0 Positive Predictive Value—11-26 percent
0 Negative Predictive Value—85-96 percent
As with any screening procedure, the accuracy of the DRE depends in part on the skill
and experience of the examiner. However, it is inexpensive, relatively noninvasive and
nonmorbid, and it can be taught to nonprofessional health workers (Waj sman & Chu,
1987).
Prostate-Specific Antigen

More promising than the DRE as a screening test is the measurement of serum

PSA. This test has been examined in several observational settings, both for initial

l7

diagnosis of disease and as a tool to monitor for recurrence after initial therapy (Partin &
Oesterling, 1994). According to Scardino (1989), parameter estimates for this test
include:
0 Sensitivity in the range of 70 percent
0 Positive predictive values of 26-52 percent

The potential value of the PSA test appears to be in its simplicity, objectivity,
reproducibility, lack of invasiveness, and low cost. It is therefore commonly used as an
adjunct to or replacement for the DRE. The PSA test has increased the detection rate of
early-stage cancers, many of which may be curable by local modality therapies (Catalona
et al., 1993). Circumstantial evidence favoring screening for prostate cancer is analogous
to that for lung cancer screening in the 1950’s and 1960’s; screening results in a shift to a
higher proportion of cases with earlier-stage cancers at diagnosis (for lung cancer, no
mortality benefit results (Collins & Barry, 1996)), possibly resulting in mortality
reduction. However, the possibility of identifying an excessive number of false positives
in the form of benign prostatic lesions requires that the test be evaluated carefully. A
nested case-control prospective study with ten years of follow-up reported that a single
elevated PSA greater than 4.0 ng/ml predicted subsequent cancer with a sensitivity of 71
percent for the first five years and a specificity of 91 percent for the first ten years of
follow-up. The cancers diagnosed were characterized by stage and grade to be clinically
significant. Forty-two percent were extracapsular at diagnosis (Gann et al., 1995).
Experience with repeat PSA screening suggests that tumors detected on a follow-up value
of 4.0 ng/ml is fi'equently used to prompt prostate biopsy; further screening studies have

also demonstrated that lowering the PSA cutoff will substantially increase the number of

l8

cancers detected, particularly in Afiican-American men (Smith et al., 1998). However,
lower cutoff PSA values are associated with high proportion of negative biopsies or false
positive results (Lodding et al., 1998). An initial PSA of less than 2.5 ng/rnl is associated
with a very low risk of cancer detection within a four-year follow-up (Harris et al., 1997).

Methods are currently under evaluation to improve the specificity of PSA (Dalkin
et al., 1993). Ratios of PSA to gamma-seminoprotein and free complexed PSA have the
effect of amplifying the differences in PSA levels for prostate cancer and benign prostatic
hyperplasia (Recker et al., 1998), but they cannot distinguish cancer from inflammation
(Jung et al., 1998). In a small study that included 26 cases with negative results from the
DRE, Catalona et al. (1995) found that prostate volume in the absence or presence of
prostate cancer is correlated with the percent of free (compared with total) serum PSA,
making volume standardization necessary. The percent of free PSA was not associated
with either pathologically-advanced cancer or Gleason scores. Evaluation in a screened
population has not confirmed a statistical advantage to the use of the ratio free-to-total
PSA when compared to total PSA alone (Bangma et al., 1995). However, that free-to-
total PSA ratios can increase the specificity for identification of cancer has been
demonstrated in other population studies (Vashi et al., 1997). Carter et al. (1990), using
frozen serum from 18 patients, concluded that an annual rise of PSA level of 0.8 ng/ml
warranted a biopsy. In a follow-up study that used serum collected serially from men
without known prostate cancer, two groups with benign prostate hyperplasia (BPH)—one
diagnosed by histology and the other clinically—both with PSA levels less than or equal
to 10 ng/ml, and a third group with no more than one PSA exceeding 10 ng/ml, these

investigators observed that averaging three PSA changes measured at two-year intervals

19

could be useful for cancer discrimination, while changes measured at three and six-month
intervals were volatile and nonspecific, perhaps because of up to 30 percent biological
fluctuations of PSA (Carter et al., 1995). Finally, Brawer et a1. (1992) followed 1,249
men screened by PSA and concluded that patients with a 20 percent annual increase in
their PSA levels should undergo further evaluation.

Medications should be listed for men undergoing PSA screening since some
medications lower the PSA values. The reason the patient is taking the medication
should also be noted. Proscar will decrease PSA levels and alter prostate cancer
detection. Alternative medications should also be listed, such as Saw Palmetto, as they
may decrease PSA levels as well. Proscar and Saw Palmetto are often given to men with
BPH (NCI, 1999).

Imaging Procedures

Imaging procedures have been suggested as possible screening modalities for
prostate cancer. Prostate imaging is possible by ultrasound, computed tomography, and
magnetic resonance imaging. Each modality has relative merits and disadvantages for
distinguishing different features of prostate cancer. Ultrasound has received the most
attention, having been examined by several investigators in different settings.
Waterhouse and Resnick (1989) report that ultrasound has low sensitivity and specificity
with regard to the values necessary for screening.

0 Sensitivity ranged from 71-92 percent for prostate carcinoma.
0 Sensitivity ranged from 60-80 percent for sub-clinical disease.
0 Specificity values ranged from 49-70 percent.

0 Positive predictive were in the 30 percent range.

20

The sensitivity and positive predictive value for ultrasound as a single test may be
better than for the DRE. However, the rate of cancer among ultrasound-positive subjects
on whom DRE and PSA examinations are normal is extremely low (Cooner et al., 1988).

When used together, the DRE and PSA test are highly effective for prostate
cancer detection. On the other hand, the ultrasound is more useful used as a diagnostic
tool in adjunct to further evaluate any positive PSA and DRE findings.

Prostate Cancer History
Age

Prostate cancer is rarely seen in men younger than 50 years of age; the incidence rate
rises rapidly with each decade thereafter. The age-adjusted incidence is higher in Afi‘ican-
Amen'can males (142.0 per 1000) compared with Caucasian males (108.3 per 1000)
(Steinberg et al., 1990). Although the prevalence of prostate cancer found at autopsy steadily
increases for each decade after 50 years, many of these cancers are clinically silent. The
tumor doubling time is long in the range of months to years and the ability of a given tumor
to progress is highly variable (Kolonel et al., 1987).

It is difficult to determine whether BPH is a risk factor for prostate cancer because
both are common diseases in men as they age, although both diseases appear to be
androgen-dependent for growth. BPH arises most ofien in the central or transitional zone
of the prostate, and cancer is most ofien found in the peripheral zone of the gland.
Kolonel et al. (1987) found that, for men younger than 70 years, more men with history
of prostate cancer had a history of BPH than did the control population. It remains

unclear whether BPH is associated with prostate cancer.

21

Race/Genetics

Several studies suggest that the incidence of prostate cancer is increased in male
relatives of patients with prostate cancer (Theissen, 1974). Cannon et al. (1982) reported
a higher incidence of prostate cancer in Utah Mormon men who have a close relative
with breast cancer. Spitz et al. (1990) showed an increase among men with first-degree
relatives with the disease. Caterband et al. (1992) have done a series of link analyses that
show men with a father or brother with prostate cancer are twice as likely to develop
prostate cancer than men without affected relatives, and that risk increases with an
increasing number of affected relatives. They go on to show that, through segregation
and linkage analyses, early-onset prostate cancer may be inherited in an autosomal-
dominant fashion. These data demonstrate an increased risk for the development of
clinical prostate cancer in men with affected first-degree relatives (Pienta & Esper, 1993).

A recent study from the NC] (1999) based on data extracted from the Surveillance
Epidemiology and End Results Program (SEER), as well as census data, reveal that
Afi'ican-American men living in the United States have a higher incidence rate of clinical
prostate cancer than do Caucasian men of similar education and socio-economic class.
The age-adjusted invasive prostate cancer incidence rates in the tri-county metropolitan
Detroit area, as measured by the SEER database in 1990, showed a 30 percent greater
incidence among Afi'ican-American men compared with Caucasian men. Afi‘ican-
American men have a higher incidence of prostate cancer at all ages. The five—year
survival rate for African-American men is 62 percent, as compared to 72 percent for

Caucasian men. The risk increases with an increasing number of infected relatives

(Pienta & Esper, 1993).

22

Other Biological Characteristics

The interaction of steroid hormones with the development of prostate cancer is
poorly understood; however, a low-fat, high-fiber diet has been shown to affect male sex
hormone metabolism by decreasing circulating testosterone (Adiercrentz, 1990).
Testosterone is necessary for normal prostate epithelium to grow, and early prostate
cancer has been shown to be endocrine-dependent (Carter et al., 1990). Hormones,
especially prolactin and estrogen, may play an undefined role in prostate metabolism
(Rannikko & Adiercrentz, 1983). Estrogens are also a successful form of hormonal
therapy for metastatic prostate cancer (Carter et al., 1990). Ross et al. (1986)
demonstrated that young Afiican-American men had serum testosterone levels that were
approximately 15 percent higher than their Caucasian counterparts, and they have
suggested that this difference is enough to explain the increased risk for prostate cancer in
African-American men. In a related study comparing American and Japanese men, these
investigators found that American men had higher levels of sex-hormone-binding
globulin than did their Japanese counterparts (Ross et al., 1992). Similarly, Meikle et al.
(1987) demonstrated a higher sex-hormone-binding globulin level in men with prostate
cancer compared with controls, and also noted a higher testosterone conversion rate in
patients with prostate cancer. Furthermore, both Afiican-American and Caucasian men
in the United States had higher levels of 3-alpha, 17-beta-androstenediol glucuronide and
androsterone glucuronide, two androgens that are indices of 5-alpha-reductase activity,
the enzyme in the prostate that converts testosterone to its active metabolite,

dihydrotestosterone. Because dihydrotestosterone is responsible for meiotic activity of

23

the prostate, this lower enzyme level may contribute to the lower incidence of clinical
prostate cancer observed in Japanese men (Ross et al., 1992).
Personal Health Habits

No definitive links between prostate cancer and viruses have been established. In
a small study, Schumann et al. (1997) found that men with prostate cancer had higher
titers of herpes virus and cytomegalovirus than did a control population. Several
investigators have studied the history of men with prostate cancer in an effort to
determine how sexual behavior and fertility is related to the development of prostate
cancer. There have been no definitive studies suggesting that sexual behavior and/or
fertility is related to prostate problems (Centifanto et al., 1973).

Environmental

Differences in socio-economic status, especially those between African-American
and Caucasian men, have been suggested as a reason for the differences in prostate
cancer incidence between these two groups. Baquet et al. (1991) at the NCI recently
investigated the incidence of prostate cancer in Afi'ican-Americans and Caucasians by
correlating cancer incidence with population density, education, and income level. Other
studies related to socio-economic status have found no relationship between educational
level and prostate cancer incidence (c.f., Schumann et al., 1997).

This literature review suggests that rigorous evaluation of any prostate cancer
screening modality is mandatory because the natural history of the disease is so variable
and appropriate treatment is not yet clearly defined (Whitrnore, 1994). Furthermore,
there is a possibility of unnecessary morbidity associated with diagnosis and treatment of

many prostate cancer lesions. A meta-analysis of six expectant series demonstrates that

24

patients with low-grade disease can experience prolonged survival with deferred therapy
(Chodak et al., 1994). Decision analyses using Markov models yield variable treatment
outcomes due to the uncertainty regarding metastatic rates expected for prostate cancers
and uncertainty about treatment efficacy (Beck et al., 1994). However, a review of the
SEER registries demonstrates that men with poorly or moderately differentiated disease
have an improved survival rate if treated, rather than followed on a program of
observation (Lu-Yao & Yao, 1997). It is not known to what degree this can be attributed
to treatment effect, as opposed to such other factors as preponderance of relatively
healthy patients in the treated group. A simulation model based on available evidence
suggests that if there is a benefit to screening, this benefit will decrease with age (Coley
et al., 1997).

In summary, the detection of prostate cancer is largely, if not entirely, due to
increased detection due to screening, and not to an increase in the actual number of
prostate cancers. This literature review indicates that increased screening for the disease
is likely a major reason for the dramatic increase in the published incidence rate.

The NCI recommends that the DRE and PSA test be performed on all men age 50
and older. African-American men and men that have a family history of cancer should
begin screening with a DRE and PSA test at age 40. Unfortunately, most men do not
know the NCI guidelines and rely on their healthcare provider, or the clinic they go to, to
tell them what screening needs to be done. Discussed in this paper are possible benefits
to early screening being reviewed with patients, especially if they are African-American
or have a family history of cancer. Discussing prostate screening with patients and their

families early on has a large potential for decreasing barriers in the future, when

25

screening will need to be done. Such preemptive discussions should be standard in all
healthcare fields. African-American men and high-risk men between ages 40 and 50, and
Caucasian men over age 50, all are being under-screened for prostate cancer. This sad
fact can be changed with education for the professional caregiver about the latest
screening modalities, their relatively low costs, and their outcome statistics.

The literature is sparse in the area of how the Afiican-American man or the man
with a history of cancer in his family is being made aware about the availability of
screening for prostate cancer. Even though the man at age 50 is recommended to have a
DRE and a PSA test, they are often not performed. The DRE and PSA test are not
understood by the general public, and perhaps therefore are avoided. For the uninsured
and those without access to care, the healthcare provider and the community have the

responsibility to offer free lectures and exams at clinics.

CHAPTER FOUR

Methods

For this paper, a prostate education letter with a lecture outline and a prostate
cancer fact sheet will be mailed or personally delivered to surrounding healthcare
providers in Washtenaw, Livingston and Monroe counties. Other target audiences will be
college and university nursing and medical programs, healthcare organizations, HMOs,
the media, and the general public. The goal is to provide up-to-date information on

prostate cancer screening.

Prostate Screening Education for Healthcare Providers

Remarkable progress has been achieved during recent years on the earlier
diagnosis of prostate cancer. This progress results largely from the rational use of the
PSA test, which is by far the most powerful tool for the early diagnosis of prostate
cancer. In fact, with the available technology, close to 100 percent of prostate cancers
can now be diagnosed at the clinically-localized stage when cure is a possibility, thus
practically eliminating the diagnosis of metastatic and non-curable disease (Labrie et al.,
1996). Following rigorous scientific evaluation, the 4.0 ng/ml should be used as the
upper limit of normal serum PSA (Labrie et al., 1992). Accordingly, a serum PSA value
above 4.0 ng/ml indicates a high risk for prostate cancer. In fact, at first screening of men
between ages 45 and 80, a serum PSA value above 4.0 ng/ml corresponds to a risk of

approximately 20 percent of having detectable prostate cancer, while the risk is decreased

26

27

to only one percent for men having serum PSA at or below 4.0 ng/ml (Labrie et al.,
1992). In the presence of a serum PSA value above 4.0 ng/ml, firrther tests such as the
ultrasound should be done in order to determine the presence or absence of cancer (N C1,
1999).

The prostate screening lecture and fact sheet (Appendix B) was developed to aid
healthcare providers and their support staff in identifying at-risk patients for prostate
cancer and to list current screening modalities used. Prostate education should be talked
about with every male during the history and physical. Screening education assists the
healthcare provider in diagnosing prostate cancer at the clinically localized stage, thus
eliminating the diagnosis of metastatic and noncurable cancer.

Prostate Screening Education for the Public

Prostate cancer screening information for the public will be offered in the
healthcare provider’s office with lecture content geared toward the patients. A
question/answer session will follow.

Prostate screening for the risk factors of age, race, and family history should
always be done on every man, regardless of age. Follow-up is an important aspect of
health care and if the PSA is elevated, even slightly, follow-up for a year to evaluate any
changes in serum level is suggested. The timeframe for follow-up is three months, six
months, and one year (NCI, 1999).

As mentioned before, screening begins at age 40 for Afiican-American men and
men with a family history of cancer, and at age 50 for all other men. African-American

men have the highest risk for prostate cancer, with Asian men having the lowest risk, and

28

Caucasian men falling in-between. With this in mind, healthcare professionals need to
culturally assess their patients for risk factors.

Follow-up of the patient is very important for his emotional well—being and
health. A DRE is done with a PSA test at age 40 for the high-risk man and at 50 for all
others; if the values are normal, the man should be screened in two years if he has no risk
factors. The man should be re-screened in one year if he has risk factors. If the PSA is
elevated, a PSA test in three months is a good evaluating point for the patient and
physician to assess for prostate cancer, BPH, or prostatitis (N C1, 1999).

Evaluation of the Project

Evaluation of this educational intervention will be straightforward. Prior to the
lecture program, each provider and their support staff will be administered a
questionnaire concerning their attitude toward and current degree of compliance with
NCI prostate screening guidelines. Six months following the lecture program, this
questionnaire will be administered again. In addition, charts from that practice will be
reviewed at random until 50 men have been identified who (a) had a physical
examination during that six-month period, (b) should have been screened for prostate
cancer at that time, according to NCI guidelines, and (c) had a previous physical exam
with that same provider at which they also should have been screened. Positive outcome
indicators for this project will thus be (1) improved beliefs concerning prostate screening
according to the questionnaires, and (2) improved compliance with prostate screening

guidelines according to chart reviews.

CHAPTER FIVE

Nursing Implications

The high incidence of prostate cancer makes it an important target for cancer
control measures. Combined DRE and PSA testing is the most reliable low-cost method
for detecting prostate cancer.

Thorough education of patients by a well-informed healthcare provider, both
before and after DRE and PSA testing, is needed to address the implications of screening
and possible therapeutic interventions. When talking about prostate cancer testing, a man
should tell his healthcare provider about any male relatives who have had prostate cancer
and how old they were when it was detected. The man should include the men on his
mother’s side as well, this is genetically just as important. Family histories of other
cancers, especially breast and ovarian cancer, should also be mentioned.

To target audiences for prostate cancer screening the, Advanced Practice Nurse
(APN) should:

0 develop targeted education and outreach programs for Afi'ican-American men that
focus on prevention, early detection, and up-to-date information on prostate cancer
screening. Afi'ican-American men have higher prostate cancer incidence and
mortality rates than Caucasian and Asian men.

0 provide access to up-to-date information on prostate cancer treatment. Resources

include the NCI’s Cancer Information Service at 1-800—4-CANCER.

29

30

0 encourage men to talk to their healthcare provider about early detection of prostate
cancer.

0 provide education about prostate screening to healthcare professionals and their
support staff.

0 continue outreach programs for prostate screening, as well as recent research
information.

The APN should present prostate screening information to HMOs, university nursing and

medical programs, hospital clinics, and healthcare provider offices for their professional

and support staff.

Patient education about prostate cancer screening/early detection and treatment
should be in various formats (e.g., videos, booklets) and settings (e.g., workshops,
churches, physicians’ offices) to educate the public. Prostate cancer information
materials should be reviewed and updated periodically so that informed decisions can be
made regarding screening and/or treatment.

Issues that require further study would be looking at the long-term benefits from
early detection from screening and treatment choices. A single standard of care for
prostate cancer has not yet been established. The healthcare professional and the patient
must individually assess each case.

Research is needed in the area of effectiveness, cost, and complications in relation
to the benefits of early detection methods and treatment alternatives. The effectiveness of
various strategies for communicating information about prostate cancer to the general
public, high-risk men, men diagnosed with prostate cancer, and healthcare professionals,

is in need of evaluation as well.

31

Conclusion

In summary, there are many implications for nurses in advanced practice. This
scholarly paper aims at providing health promotion to the public in a way that is
accessible and understood, by communicating the importance of prostate screening to the
healthcare provider and by educating the public in a well-informed manner.

The APN can assist a patient to remove barriers that they might have regarding
information needed for access to care and to clear up any ambiguity about exams. APNs
can research the area of prostate screening, lecture to the public, assess cost and
education, and evaluate outcomes within their patient population with pilot studies. Such
studies can be quantitative in nature, evaluating how many men within the age, race, and
high-risk categories are indeed being screened in a primary care setting.

Research on cures for prostate cancer is ongoing. Screening for prostate cancer
thus remains the only way to add years to a man’s life. It is of the utmost importance that
all healthcare providers screen men for prostate cancer.

The educational materials developed should increase prostate screening in
primary care offices. I will advocate for prostate cancer screening guidelines from
HMOs and insurance companies. The prostate screening lecture and fact sheet will
increase understanding of the importance of this exam by healthcare professionals, their

support staff, and through them, the lay public.

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(1997). Epidemiologic study of prostate cancer: A preliminary report. Cancer Treat.
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Spitz, M. R., Currier, R. D., Fueger, J. J ., Babain, R. J., & Newell, G. R. (1990).
Familial history and the risk of prostate cancer. Prostate, 16, 187-197.

Steinberg, G. D., Carter, B. S., & Beaty, T. H. et al. (1990). Family history and
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38

Waj sman, Z. & Chu, T. M. (1987). Detection and diagnosis of prostatic cancer. In
Murphy, G. P (Ed.), Prostatic Cancer (pp.94-99). Littleton, MA.

Waterhouse, R. L. & Resnick, M. I. (1989). The use of transrectal prostatic
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TABLES

39

Table l - PSA Reference Ranges Comparison by Age and Race (Moyad

 

 

& Oesterling, 1997)
Age Range Asians Blacks Whites
40-49 0-2.0 0-2.0 0-2.5
50 0-3.0 0-4.0 O-3.5
60-69 0-4.0 0-4.5 0—4.5

70-79 0-5.0 0-5.5 0-6.5

 

FIGURES

40

Figure l. Pender’s Revised Health Promotion Model

Individual
Characteristics
and
Experiences

 

 

Prior
related
behavior

 

 

 

 

Personal
factors;

biological ->

psychological
socio-cultural

 

 

 

l—

Behavior-
Specific
Cognitions
and Affect

 

Perceived
benefits
of action

 

 

Behavioral
Outcome

 

 

Perceived
barriers
to action

 

 

 

Perceived

"‘ Self-efficacy

 

 

 

Activity-related
affect

 

 

 

 

 

Immediate competing
demands
(low control)
and preferences (high
control)

 

 

 

 

 

V

Commitment Health-

to a promoting
plan of action behavior

 

Interpersonal
influences
(family, peers,
providers); norms,

 

 

it

 

 

support, models

 

 

 

 

 

 

 

 

Situational
influences;
options
demand characteristics
aesthetics

 

 

 

 

 

 

Individual

Characteristics

and
Experiences

41

Behavior-
Specific
Cognitions
and Affect

Figure 2. Lesse’s Modified Revised HPM

Behavioral
Outcome

 

 

Perceived
benefits
of action

 

 

 

 

 

 

Prior
Related
behavior

 

Perceived
barriers to action

expenses
inconvenience

 

 

 

 

 

Perceived
self-efficacy

judgmentto act

 

 

 

 

Activity-related
affect
feeling of action
(0 or (-)

_l

 

Commitment
to a

 

 

 

 

Personal factors;
biological
psychological
socio-cultural

 

 

 

 

 

Interpersonal
influences
(family, peers,
providers); norms,
support, models
beliefs, attitudes

plan of action
mutually
Iareod on
action

 

 

I

 

 

 

Health
promoting
behavior
«Marne of
action

 

 

 

 

 

 

 

 

Situational
influences;
options
demand characteristics
aesthetics
precepting behavior
(0 or (-)

t

 

 

 

 

 

 

 

 

 

APPENDICES

APPENDIX A

42

Cover Letter for Primary Care Practitioners

Dear Colleague,

I have been researching the screening procedures for prostate cancer in men, and have
discovered that most men do not receive the screening for prostate cancer that they
require.

The NCI guidelines suggest that the healthcare profession look at:

J Age—Age 40 with risk factors, age 50 for all others
I Family history—Family history of cancer on either side
J Race—African-American

Dr. Catalona stated in 1999 that, “At least 47 percent of men ages 40-59 have never heard
of a prostate specific antigen (PSA) test. An amazing 60 percent of men between the
ages of 40 and 59 say their doctors have never talked about the PSA test, 43 percent of
men over 50 have never had the test, of men over 40 with a family history of prostate
cancer, 35 percent have never been tested and their doctors have never discussed the PSA
test.”

I am in the process of going into clinics and colleges and talking with insurance
companies about the screening being done and how to comfortably incorporate this
practice into their protocol for the male client.

I have packaged an outline for you to review that discusses the latest in screening for
your patients. Enclosed, you will find two outlines—one for you and your support staff,
the other is to be presented to the patients. Also, information from the NCI about the
DRE and PSA test is enclosed.

I look forward to discussing with you a way that I can bring this information to you and
your patients in the near future.

Sincerely,

Opal Patricia Lesse RN, C, MSN, FNP

APPENDIX B

43

Prostate Cancer Facts

Risk Factors

J Age—Age 40 with risk factors, age 50 for all others
J Family history—Family history of cancer on either side
J Race—Afiican-American

Prostate Cancer Mortality Rate

J Increased for all men since 1973
J Highest for Afiican-Americans
J Estimated that 42,000 American men will die from the disease this year (N C1, 2000)

Prostate Cancer Five-Year Survival Rate

J Overall, five-year relative survival rates are high

J Caucasian men have a higher five-year relative survival rate than Afiican-American
men (NCI, 2000)

44

Prostate Cancer Incidence Rate

Age-adjusted rates of prostate cancer incidence rose 69 percent in the United
States in men from 1989 to 1992, compared with 20 percent fi'om 1985 to 1988, and three
percent from 1981 to 1984. Rates are age-adjusted to take into account the aging of the
US population. All rates cited are age-adjusted to the 1970 US standard population (N C1,
2000)

For Caucasian men, the incidence rate peaked in 1992, at 185.8 new cases per
100,000 men, before dropping 27 percent to 133.0 new cases per 100,000 men in 1994.
Incidence in Afiican-American men peaked in 1993 at 264.7 cases per 100,000 men,
before declining 11 percent to 234.4 cases per 100,000 men in 1994 (NCI, 2000).

There is a broad agreement that increased use of the PSA screening test after 1989
created an artificial rise in incidence rare.

In 1995, NCI researchers published a study that linked the sharp rise in new cases

from 1986 to 1991 to increased use of the PSA blood test.

45

Prostate Cancer Mortality

Since 1977, there has been a gradual increase in prostate cancer mortality rates.
The rate increase sped up slightly in the mid 1980’s, before mortality rates began to drop
slightly in 1992.

The prostate cancer death rate for white men began dropping in 1992, and for
Afiican-American men in 1994. The rate declined 6.3 percent overall from 1991 to 1995.

Lead time is the period between when cancer is detected through screening tests
and when it can be clinically detected. Researchers estimate that on average, PSA
screening detects prostate cancer five or more years earlier than a DRE.

In 2000, the NCI is conducting a large-scale randomized study to determine
whether the DRE and PSA test will reduce deaths due to the disease. The prostate, lung,
colorectal, and ovarian cancer screening trial will follow progress of 74,000 men and
74,000 women. Half of the study participants are being regularly screened for the

cancers under study, and half receive usual medical care.

APPENDIX C

46

Prostate Cancer Screening

There are two screening tests for prostate cancer, the prostate specific antigen
(PSA) test and the digital rectal examination (DRE).

The PSA test is a blood test that screens for the prostate antigen. If the blood test
is above 4.0 ng/ml, then further testing will be done. Some conditions will raise PSA
levels, such as infection or benign prostate hyperplasia (BPH).

The DRE is an exam where the prostate is felt manually. If enlarged, the
healthcare provider might order a PSA test to further rule out cancer. BPH will enlarge
the prostate as well.

It is very important to tell your healthcare provider if you are taking any
medications like Proscar or Saw Palmetto, since these medications can falsely lower PSA
levels.

Risk Factors for Prostate Cancer
Age: if you are 40 and African-American or have cancer in your family history, you need
a prostate exam. If you are 50 or over you need a prostate exam.
Race: Afiican-Americans are at highest risk, according to studies, Asian men are at
lowest risk. Caucasian men fall in-between.
Family History: If you have cancer on either side in your family, you are at risk for
prostate cancer.

How to Be Tested

Call your healthcare provider’s office, or health department to ask about free

screening. Insurance will pay for this exam. For Questions call the NCI’s hotline: 1-800-

4-CANCER.

 

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