Summary
In this study, it was found that black males opt for investigation for possible prostate cancer less frequently than white males; this did not appear to be related to any specific, recorded, patient characteristic. This lower preference for investigation in black males was particularly marked when the risk of cancer in the vignette was low: less than half of black males opted for investigation when the risk of prostate cancer was the lowest value offered (namely 2%). In contrast, white males had a very high preference for investigation, including at the 2% risk level.
Several factors were not significantly associated with black males’ preferences for investigation, including age, income, employment status, convenience of the nearest main hospital, or a family history of cancer.
Strengths and limitations
To the authors’ knowledge, this is the first study to examine ethnic differences in the desire to be tested for prostate cancer. This study built on a previous, successful project that was not powered to explore ethnic differences; as a result, much of the design and piloting for this study had already been performed, and procedural problems overcome.
The vignettes were realistic and used primary care data to provide estimates of the actual risk of prostate cancer.11 In addition, the electronic nature of the questionnaire minimised missing data and was accepted by 80% of patients who often have a long waiting time, with few or no distractions. The response rate of >80% was excellent, and there was no obvious difference by ethnic groups in those declining to participate.
However, some limitations are present. Black male patients (who have a higher incidence rate for prostate cancer) were compared with white male patients; as a result, the findings cannot be generalised beyond these two groupings. In addition, two black ethnicities (black–black British African and black–black British Caribbean) were grouped together; there are many different black ethnic groups, which may have different views on the advantages of testing for prostate cancer.
A further limitation is that only prostate cancer was studied so it is not possible to determine whether the lower preference for investigation in black males would also be found for other cancers, or in black females. Furthermore, the sample population comprised GP attenders. Although conducting the study in the GP practice offered the major advantage of providing translation where needed, and being the setting where initial investigation for prostate cancer takes place, it is not possible to determine whether a true community sample, or a sample in other cities, would have yielded different results. That said, there is no reason to think this would be the case.
The final consideration is whether vignettes give valid answers. This was discussed relatively widely in Banks et al ’s recent study: most, but not all, studies considered vignettes to provide meaningful responses.12
Comparison with existing literature
Overall, 81% of the sample participants opted for investigation in the first vignette. This proportion is lower than the 88% reported in Banks et al ’s study (although 89% of participants in that study were white British); the differences by risk groups in that study were also slightly larger. In the study reported here, 94% of white males opted for investigation; this may reflect the different cancer site: prostate, as opposed to colon, pancreas, or lung. Prostate cancer is generally found in older males, has lower mortality rates, and is relatively more common in black males; all of these factors make it somewhat atypical.
There was a general increase in the preference for investigation with higher risk of cancer in black males; a finding reported by Banks et al,12 although in that case it was largely driven by their colorectal findings. The rationale appears logical; it was not seen in white males but this could be a result of their high overall preference for investigation.
This study’s findings of a lower preference for investigation in black males, compared with white males, could perhaps indicate why it has been found that emergency presentations are increased, and mortality and staging at diagnosis are worse, in black males.3,4,15 The current findings are based on a vignette that presupposed entry into health care, and strictly does not extrapolate on the decision to seek health care when a man has symptoms; however, it is plausible that a lower desire for investigation may also engender a lower desire to seek help.
Black males have been reported to have a worse fear of prostate cancer when compared with white males.4,16 They fear that the disease could be terminal and that its treatment could lead to severe sexual disorders (such as erectile dysfunction, sterility, and decreased sex drive), which, in turn, may change their close relationships with their spouses.16,17 Several (mainly US) studies have highlighted fear as a major deterrent to black males’ medical help-seeking, even when experiencing lower urinary tract symptoms.16 This factor may explain some of the views expressed by black males in this study rather than assuming that they were making accurate judgement of their cancer risk. It is also well recognised that black males do not like visiting doctors and may be influenced in their healthcare seeking by family members;18,19 interestingly, however, a specific family history of cancer did not appear to be important in the current study.
Conversely, patients’ knowledge of prostate cancer signs and symptoms, investigative procedures, and possible outcomes of treatments may influence their willingness for investigation.17,20 Males of both ethnicities have similar knowledge of prostate risks and symptoms,4 although black males tend to underestimate their personal risk of the disease,21 and are often less conversant with the PSA and rectal examination procedures, and may abstain from investigation altogether due to this.17,20 Some black males perceive rectal examination as a threat to their masculinity and consider it an undignified test.17,20 They are also more likely to be too embarrassed about lower urinary tract symptoms and generally less comfortable seeing their GPs compared with their white counterparts.4,22 These factors, in addition to language or communication barriers, stigma, and socioeconomic deprivation may provide an alternative explanation to black males’ reluctance for prostate cancer investigation when symptomatic.
Models of behavioural change (for example, the health belief model and self-regulatory models) have been used to explain patients’ attitudes towards cancer screening and early diagnosis.23,24 The questionnaire in this study did not collect specific information to assess this, although the main reasons cited by participants for choosing or declining investigation provide useful insights in this regard. In total, 86% of those declining prostate cancer investigation were black males, around half of whom cited low risks as the main reason for their choice. This is consistent with the findings of a US study, which reported moderate perceived susceptibility and perceived severity of prostate cancer in black males.24 Worryingly, 37% of those who declined indicated that they would rather not know they have cancer; this, again, echoes their fears of the disease and perceived negative consequences of it being diagnosed.
In both groups who opted for investigation, early detection of prostate cancer was the main reason cited for their decision, and black males cited peace of mind almost as frequently. White male reasoning in this situation may be interpreted in line with their perceived benefits of treatment and curability of the disease, while black males’ views may, again, reflect their greater fear of prostate cancer diagnosis and possible treatment outcomes.
Implications for practice
The pathway to diagnosis of symptomatic prostate cancer is complex, the success of which depends largely on prompt presentation of symptoms to primary care and prompt referral to secondary or specialist care. Both stages may be influenced by patients’ preference for diagnostic investigation. GPs should be aware of the reduced appetite for testing in black males (which is possibly linked to fear and perceived negative outcomes of a prostate cancer diagnosis) and may consider being proactive in discussing the subject. This is particularly important as a study has suggested lower self-initiated discussion with the doctor about prostate cancer in black Caribbean males (as measured in native-born and foreign-born black males in the US).25
Prostate cancer awareness campaigns currently targeting black males may prove less effective where patients are unwilling to take up diagnostic investigation. Campaigners may consider including information about testing procedures and promote the benefits of early diagnosis. This is especially relevant as black community groups are increasingly keen to see PSA screening become available. If such campaigns could also incorporate encouragement for symptomatic testing, the differences reported in this study may narrow.
Black males, who have a higher incidence of prostate cancer and a higher mortality from it, are less inclined than white males to be tested for the disease. Education targeted at the black community and the health professionals who treat them may help to address this.
