The overall prevalence of PSA screening of men aged 40 years and older was 26.3% in 2005 and 27.5% in 2010. As shown in Figure 1, men aged 70 to 74 years had the highest prevalence of PSA testing (49.0%). The frequency of PSA screening in 2005 and 2010 were similar for each age group. We assessed the prevalence of PSA testing and SDM factors based on data from the 2010 NHIS. Among men aged 70 years and older, 44.1% (95% CI, 40.5–47.8) reported having had a PSA test, 41.7% (95% CI, 38.0–45.5) reported having a discussion about the advantages, 20.1% (95% CI, 17.5–23.0) reported having a discussion about the disadvantages, and 15.1% (95% CI, 12.7–18.0) reported having a discussion about scientific uncertainties. Among men who underwent PSA testing, only 27.2% (95% CI. 22.2–32.9) reported having discussions about both advantages and disadvantages (data not shown).

Findings from the unadjusted analysis (Table 1) showed that all variables examined were significantly associated with PSA testing except for family history of prostate cancer and comorbidity. The percentage of PSA testing was significantly lower among men aged ≥80 years (37.0%; 95% CI, 31.4–43.0) than among men aged 70 to 74 years (49%; 95% CI, 43.0–55.0). Discussions of advantages only and of both advantages and disadvantages were significantly more likely than no discussion to result in PSA testing.

Findings from the multiple logistic regression analysis (Table 2) revealed that after controlling for all other variables in the model, the prevalence of PSA testing was significantly higher among men who reported having had a discussion about advantages only (57.4%; 95% CI, 48.9–65.4) or about both advantages and disadvantages (55.9%; 95% CI, 46.9–64.6) compared with men reporting no discussion (34.3%; 95% CI, 29.2–39.9). Significantly higher prevalence of PSA testing was observed among men aged 70 to 74 years compared with men aged ≥80, among college-educated men compared with men with less than a high school education, and among married men or those living with a partner compared with men who were divorced, separated, or widowed.

Our analysis reveals that a large proportion of men aged 70 and older are undergoing PSA-based screening for prostate cancer. More than 70% of these men reported not having discussions about advantages and disadvantages. When conversations did occur, health care providers more often focused on the advantages than disadvantages of PSA testing. Infrequent discussion of disadvantages of PSA screening had been observed by several studies.^14,16 Among these, Hall et al¹⁴ administered a national survey of physicians regarding prostate cancer screenings and found that more than two thirds of physicians who provided a prescreening discussion encouraged their patients to have the test; fewer than 2% discouraged testing. Hoffman and colleagues¹⁶ surveyed 240 men aged 40 years and older and found that health care providers more frequently emphasized the advantages of screening (71%) than the disadvantages (18%). It has been consistently reported that a physician’s advice is a major determinant in a man’s decision to have a PSA test.^19–21 Lack of SDM in the physicians’ office may result in prostate cancer screening that could cause unnecessary physical, psychological, and financial harm to patients. Prostate cancer screening guidelines from major medical organizations such as the American Cancer Society and the American Urological Association recommend that patients be fully informed by health care providers about the advantages, disadvantages, and the scientific uncertainties associated with PSA testing and that patients’ preferences should be considered in screening decisions.^7,8

In 2012, on the basis of new evidence about the benefits and harms of the PSA test, the USPSTF revised its 2008 recommendations on prostate cancer screening. The new statement does not recommend routine PSA-based screening for any men, regardless of age.⁶ The USPSTF understands that screening decisions may differ based on patient-specific characteristics and clinical situations and emphasizes that men and their health care providers should continue to discuss the advantages and disadvantages of PSA testing for prostate cancer screening and that they should make informed decisions about whether testing is right for them. Efforts are needed to enhance physicians’ knowledge of and adherence to these SDM recommendations before ordering a PSA test.

We found that discussions of both advantages and disadvantages were associated with a higher prevalence of PSA test use. Similar findings also was observed by Ross and coworkers²² in an analysis of 2000 NHIS data and by Tannor et al²³ in a study of African American men. However, in both of these studies it was not clear whether physicians provided balanced information on the harms and benefits of prostate cancer testing and whether patients were fully engaged in the discussion. Besides varied levels of knowledge among health care providers about SDM and how to conduct it, misaligned financial incentives for physician practices might partially account for encouraging PSA testing; physicians with a laboratory on site are more likely to order a PSA test.²⁴ Similarly, higher levels of PSA testing have been observed in Veterans Affairs hospitals with primary care incentives compared with institutions without incentives.²⁵ Thus, the nature, context, and extent of physician-patient discussions of advantages and disadvantages of PSA screening must be studied further. In addition, our study revealed that a discussion about scientific uncertainties had no influence on PSA testing and that educational attainment and marital status were associated with a higher prevalence of PSA testing, as seen in other studies.^11,13,22 Therefore, it is important to assess knowledge of and perspectives on prostate cancer screening among patients and their family members and educate them on how to make decisions consistent with their values and clinical needs.

Our study is subject to several limitations. First, the NHIS data were self-reported and are thus subject to recall bias. Self-reported screening behaviors may have been overestimated as a result of social desirability.^26,27 Second, responses to SDM questions were structured as yes/no, lacking detailed information to understand what was discussed and whether the discussions were appropriate. Third, we were not able to assess men’s knowledge, values, and preferences on prostate cancer screening to provide a more complete picture of SDM because this information was not collected by the survey. Last, given that the response rates ranged from 60% to 70%, our population-based estimates might be suboptimal. However, the calculations of weights, which were adjusted for differences in probability of selection and nonresponse, might have partially corrected the bias.

Our study suggests that the 2008 USPSTF recommendation had little effect on prostate cancer screening. A large number of older men have continued to undergo PSA testing, and more than 70% of these men reported not having discussions with their physician about advantages and disadvantages. Given the 2012 USPSTF recommendations that routine screening should not be performed in any age group of men, discussions between providers and men about the harms and benefits of prostate cancer screening is even more important. Discussions of advantages only and of both advantages and disadvantages of PSA testing seem to increase the uptake of prostate cancer screening. However, discussions of scientific uncertainties had no effect on PSA screening. Additional research is warranted to better understand the nature, context, and extent of physician-patient discussions and patients’ knowledge of, values, and preferences for prostate cancer screening. This will be critical to help men make decisions that are most consistent with their values and preferences.