The prostate-specific antigen (PSA) test to screen for prostate cancer is fraught with controversy, despite being one of the most common clinical tests given to older men. A large 2009 study found no difference in cancer-specific mortality over 10 years between men who were screened for prostate cancer and those who weren’t. And in 2012, based on this and another large study, the US Preventive Services Task Force recommended against PSA-based screening for prostate cancer altogether, citing very little benefit versus the risk of false positives, invasive follow-up procedures, treatments with significant side-effects, and added health care costs.
Other groups like the American Cancer Society and the American Urological Association still recommend that men of a certain age (i.e. younger) and health status (i.e. healthier) have a discussion with their physician about screening. Many physicians—including those here at the University of Chicago—also recommend selective screening, following proper consultation with a physician on the implications and a shared, informed decision. Clearly, a number of considerations go into whether a man should be screened for prostate cancer: life-expectancy, overall health, family cancer history, doctor’s advice and the patient’s general attitude toward preventive health care.
A medical student at the University of Chicago Pritzker School of Medicine and his mentor recently conducted a study to look at how another set of factors, a man’s emotional state, figures into this decision. The results of this work were recently published in the journal Medical Care.
Ashwin Kotwal, a fourth-year student, and William Dale, MD, PhD, a geriatrician and chief of the Section of Geriatrics & Palliative Medicine, analyzed a nationally representative data set to see how men’s perceived stress, depression and anxiety affect PSA screening rates. Kotwal said that in previous research, he and Dale had found that the frequency of screening was often inversely proportional to the likely good it would do. Men who were already in poor health and had low life-expectancy, and who wouldn’t benefit from PSA screening, were still being tested at significantly high rates. Those with longer life expectancies, were not be screened nearly enough.
To understand why those differences exist, Kotwal and Dale used data from the National Social Life Health and Aging Project (NSHAP) from NORC at the University of Chicago, which is a longitudinal, population-based study of the physical, social and emotional health of older Americans. They found that men who reported higher levels of stress from external factors were less likely to get a PSA test. Men who were depressed had lower rates of screening as well, which other studies had shown.
However, when they controlled for stress, the relationship between depression and screening was no longer statistically significant, which is a new discovery. In short, it is stress, rather than depression, that decreases screening rates.
Kotwal and Dale found a third emotional component, anxiety, also affected their likelihood of being screened, but its effect differed based on how often a man saw a doctor. Men who reported high anxiety, but didn’t visit the doctor very often, were much less likely to get screened for prostate cancer. Conversely, men with high anxiety who visited the doctor a lot were much more likely to be screened. Anxiety is a “trigger” for screening, but only it you are already going to the doctor frequently.
Kotwal said this was a unique opportunity to look at all three of these distinct emotions in the same dataset, since NSHAP is unique in this way. Previous studies had looked at the effects of depression on rates of PSA testing, but this was the first to add in the additional factors of anxiety and stress, and their unexpected consequences.
“When you tease these emotions apart, they all have a unique relationship with PSA screening, which is important to recognize,” he said.
This has important implications for clinicians treating men with different emotional profiles. The results are indicative of how a person’s attitude impacts their medical decision-making. Those who visit a doctor often, and are more experienced in a health care setting, are much more likely to receive preventive services like prostate cancer screening, especially if they are anxious. Kotwal acknowledges that the PSA test is an especially interesting case, given the history of changing and conflicting recommendations.
“Right now, for prostate cancer screening the evidence is mixed on whether it ultimately benefits patients. But it’s the best tool we currently have to screen for prostate cancer. You typically have noticeable symptoms when it’s at a late stage,” he said. “So we’re kind of in a tight spot as providers. It’s either we screen men and expose them to the possibility for all these potential harms of prostate cancer diagnosis and treatment, or we don’t screen and more people will present with late stage prostate cancer.”
This situation puts a lot of emphasis on the doctors who counsel men on whether or not to get screened, and this data suggest an understanding of the nuances of how a patient’s emotions can significantly affect their decisions.
“Physicians are pretty good at judging how anxious or stressed a patient is,” Kotwal said. “So just being aware of that can help in making sure that patients are making informed decisions.” Hopefully, such attention to these emotional factors will lead to better choices for men regarding a disease that currently claims about 30,000 lives a year.
Kotwal, A., Schumm, P., Mohile, S., & Dale, W. (2012). The Influence of Stress, Depression, and Anxiety on PSA Screening Rates in a Nationally Representative Sample Medical Care, 50 (12), 1037-1044 DOI: 10.1097/MLR.0b013e318269e096