Barriers to prostate cancer screening: psychological aspects and descriptive variables – is there a correlation?

Abstract

Objective. To evaluate psychological and demographic aspects of men who received DRE during the PCa screening in an outpatient clinical setting.

Methods. Patients (345) who underwent DRE for the first time from February 2006 to December 2007 were evaluated for their psychological reactions and feelings after the examination.

Results. The average age of the patients was 52.8 years (25 - 85 years); 40.94% had felt fear (examination fear 15.94%, and diagnosis fear 25%), 26.45% shame and 48.26% indicated they were not thinking about anything. There was no correlation between age, educational level and emotional reactions. Most patients (96.8%) would undergo a DRE again and 52.35% had considered it better than they had imagined. Of these patients, 41.81% were illiterate/incomplete elementary school. Only 4.12% described having a negative experience. The factors that persuaded the patients to book an appointment were: 50.1% made their own decision, 26.67% were recommended by a physician, 18.55% family/friends and 6.67% were influenced by the media. Wives booked 24.06% of the consultations. Although 85.47% of patients had some previous knowledge about the examination, 80.81% felt they had further clarification afterward. Lower educational level was related to lack of information about DRE, while 52.38% who made their own decision had previous knowledge of the importance of DRE.

Conclusion. The majority of the patients found DRE less awkward than they had imagined it to be and would repeat the examination in the future. Fear and shame before the examination are present and are barriers to the DRE.

Keywords:

• Prostate cancer
• digital rectal examination
• screening
• psychological aspects
• barriers
• emotional

Introduction

In Brazil, prostate cancer (PCa) is the second leading cause of death in men and is due to malignant neoplasia [1]. In 2010, there are an estimated 52 new cases in every 100 thousand men [2].

The American Urological Association and the American Cancer Society [3] as well as the International Society for the Study of the Aging Male (ISSAM) [4,5] recommend PSA screening in well-informed patients for the detection of prostate cancer. The baseline age for testing should be 40 and a digital rectal examination (DRE) should be included.

A recent randomized prospective study compliance with both the PSA and the DRE screening tests was high (89%). Positivity rates for PSA and/or DRE tests increased with age, and prostate cancer detection rates among men with positive screens increased with PSA stratum and DRE findings. In this same work, the authors considered an annual PSA test and a DRE an efficient method for screening [6,7].

Fear of mutilation or damage caused by the treatment, and other misunderstanding about the possible causes of cancer, impede the process of seeking testing for early diagnosis and treatment [8]. The diagnosis creates awareness of the possibility and proximity of death [9]. Consequent anxiety leads to distortion in communication, creating difficulty in the comprehension of the information and recommendations, with detriment to the doctor-patient relationship.

However, various types of cancer can be cured when diagnosed early, depending on its staging, which is determined by the organs involved. These conditions determine the prognosis, that is, the possibility of cure, on which the treatment is based, which must be discussed with the patient and his family, as they can influence great changes in their physical and mental attitude, and in their daily routine.

Existing myths about the DRE does not only affect the prostate, it also affects the masculinity, puts it to shame [10].

We correlated the data of the demographic and psychological aspects in patients who consulted an urologist for the early detection of PCa and underwent a DRE for the first time.

Methods

Men who consulted an urologist and submitted to a DRE for the first time with the objective of early detection of PCa in the period from February 2006 to December 2007 and who had provided informed consent to participate were selected.

The study received the approval of the local medical Ethics Committee in Research – number 455/2005.

After the medical consultation, the patient answered a questionnaire created by the researchers, about personal details (age, profession, scholarship level, and race) and data about the appointment (who convinced the patient to consult and who booked the consultation).

After this they answered questions about experience (Table I).

Table I.  Questions about patient experience.

In relation to what you imagined, how did you find the examination?

Better than you imagined the same worse much worse

Mark the correct alternative(s):

Felt fear of the examination

Felt fear of the diagnosis

Felt shame

Have not thought about anything

Would you consider repeating the examination in the future?

Yes   No  Maybe

Why? _________________________________________________

Did you have any information about the importance of this examination beforehand?

Yes  No

In relation of what you knew about prostate cancer, after the appointment, you fell:

More informed  Less informed

The same as before the appointment

The urologist read the questions to the illiterate patients (only 8 patients, 2.36%).

Descriptive analysis was carried out using frequency tables for categorical variables and position measures and dispersion for continuous variables [11].

Statistical associations and correlations were determined by using the Chi-square or Fisher test.

The data was analyzed using the SAS System for Windows Program (Statistical Analysis System), version 9.1.3 Service Pack 3.

The level of significance adopted was 5% with p = 0.05.

Results

The average age of the patients was 52.8 years old (25 - 85 years) and 345 patients were included, many of them with incomplete elementary school education (31.86%) and 29.5% with a tertiary qualification. With respect to race, 89.91% were White, 9.17% were Black and 0.92% was Asian. Of all the patients, 15.94% reported fear of the examination, 25% reported fear of the diagnosis, 26.45% shame and 48.26% had not thought about anything in particular. There was no correlation between age, educational level and emotional reactions.

Most patients (96.8%) would willingly undergo the DRE again and 52.35% (Table II), of whom 41.81% were illiterate/elementary school incomplete, considered the procedure better than they had imagined (Table III p = 0.0105). Only 4.12% described having a negative experience.

Table II.  In comparison to what you imagined, how did you find of the digital rectal examination?

Answer	N	Percentage (%)
Better	178	52.35
The same	145	42.65
Worse	14	4.12
Much worse	3	0.88
Total	340	100

Table III.  Correlation between scholarship and the question: in comparison to what you imagined, how did you find of the digital rectal examination?

Scholarship	Better	The same	Worse/much worse
Illiterate/elementary school incomplete	22.16	10.18	1.80
Elementary school	6.89	4.79	0.60
High school	12.28	11.38	0.60
College/master degree	11.68	15.87	1.80
Total	52.99%	42.22	4.79

p = 0.0105 (Fisher's test).

Doctors of another specialty referred 26.67% of the patients, 7.83% had been convinced by their family and friends to make an appointment, 50.14% made the decision themselves and 6.67% were persuaded by the media. Of the whole group, 24.06% had the consultation booked by their wives.

With reference to the importance of the examination, 85.47% of the patients had previous knowledge; however 80.8% considered themselves to be more informed after the consultation (Table IV). Among the patients who were illiterate or who had not completed elementary school, 10.65% reported not having prior information about the importance of the examination (p = 0.0001) (Table V) and 52.38% of the patients who made their own decision to set up the appointment had previous knowledge about the importance of the examination (p = 0.0322).

Table IV.  Questions about the patients’ level of information.

Did you have any prior information about the importance of the exam?
Answer	N	Percentage (%)
Answer	N	Percentage (%)
Yes	294	85,47
No	50	14,53
Total	344	100
In relation to what you knew about prostate cancer beforehand, after the appointment, did you feel:
Answer	N	Percentage (%)
More informed	278	80,81
Less informed	0	0
The same as before the appointment	66	19,19
Total	344	100

Table V.  Correlation between education and the question: Did you have any prior information about the importance of this exam?

Education	Yes	No
Illiterate/elementary school incomplete	23.67	10.65
Elementary school	11.24	1.18
High school	21.60	2.37
College/master degree	28.70	0.59
Total	85.21%	14.79%

p = 0.0001 (Chi-square).

The age range from 60 to 69 years old was correlated to previous knowledge about the importance of the examination (p = 0.0160).

The majority of men who found the examination better than they had imagined it would be, were illiterates and those with incomplete elementary school (p = 0.0105).

Discussion

Although it has limitations, a significant percentage of PCa is diagnosed by DRE which is useful in more selective screening procedures to decrease unnecessary biopsies and over diagnosis; furthermore around 25 % of diagnosed patients present PSA in the normal range [12].

The omission of this examination from screening protocols might compromise the diagnosis and treatment outcomes because many cancers detected by DRE alone are potentially curable but may have worse outcomes by the time PSA also reaches a higher level [13].

Nagler et al. [14] found that of 13,580 healthy men, only 78% would participate in screening that included both DRE and PSA. The results of this study demonstrated that DRE is a significant barrier to participation in PCa screening.

In the present study, only 50.14% patients themselves took the initiative to book a consultation and of these, 68.12% booked the consult themselves, which positively correlated with previous knowledge about the importance of the examination (p = 0.0322). In 18.55% of patients, the wife had convinced her husband to undergo the examination and in 24.06% she was the one who booked the appointment, denoting the importance of the role that information and women play in early PCa diagnosis.

In 26.67% of the examinations, another doctor had convinced the patient. These data show the importance of the medical professional's awareness in seeking a specialized referral. Woods et al. [15] concluded that a physician's engaging communication style, encouragement to screen and sharing prostate cancer information, as well as men understanding the serious risk of prostate cancer are significant predictors for seeking screening. On the other hand, only 6.67% were persuaded by the media.

In relation to what they imagined the DRE to be; 52.35% found it better than anticipated and 41.81% of this group were illiterate or had incomplete elementary school education (p = 0.0105). Only 4.12% found the DRE to be worse than they had imagined.

These data may suggest that imagination and beliefs may lead the men to envision the DRE as something much more awkward than it really is. These fantasies could be part of an existing myth in relation to the examination, involving aspects of human sexuality because 96.81% of the patients had said that they would undergo the examination again. Furthermore, it is related to the lack of knowledge, or misinformation, and could be reversed by more comprehensive information.

Fear was the psychological determinative key found in the behavior of men who submitted to PCa examination involving DRE, with men being equally affected across different ethnic groups, social class and severity of their symptoms [16,17]. Another study found that, despite having limited knowledge on the subject, the men considered the DRE to be embarrassing and uncomfortable [18].

In the present study, 15.94% of the patients admitted fear of the examination, 25% fear of the diagnosis, 26.45% felt shame and 48.26% had “not thought about anything”. There was no correlation between age range and the educational level and the feelings above. The emotions and defense reactions of those “not thinking about anything” were experienced by men of all ages, independent of the level of education and knowledge that they had acquired to this point.

Fear is a primitive emotion in the human being. It freezes the emotions, it perverts relations, it enslaves and it hinders the possibility of the assimilation knowledge and creativity. From this emotion defenses are built up and these prevent the human being developing beyond the beginning of the Freudian pleasure principle where they avoid pain, and reducing their capacity to experience the joy of living, which is the only emotion capable of assuring a better quality of life [19].

In the present study, 40.94% of men had felt fear of the examination or diagnosis. Adding to other recorded answers (“had not thought about anything” and “felt shame”) all the patients presented with emotional defense reactions to the DRE, alternating between a potential desire and accomplishment, inhibits the action and attitudes towards early detection.

Similar findings have been found by Forrester-Anderson [20] in groups of African American men when considering knowledge about the disease, access to screening services, embarrassment and fear of a positive diagnosis.

Macias et al. [21] showed that the examiner's gender does not affect men's perceived pain and embarrassment during an emergency department DRE, but younger males experienced more pain and embarrassment. Examiner training level and prostatic examination did not affect the pain experienced.

Pain and discomfort during the DRE examination are not negligible, but they were not sufficient to stop the patient having another prostate exam in the future [22].

Turkish men refusing to seek screening programs were not well characterized in a previous study by Ceber et al. [23]; about 51% of those who refused failed to give a reason for it, and 25% who made an appointment refused a DRE. Barriers identified included embarrassment about DRE (5.8%).

Although with no information about the number of subjects or methodology used in data collecting, Nascimento [24] showed that educational level was associated with age and these were significant elements in the acceptance of DRE. Younger men with a higher level of education were less hesitant about having a DRE compared to older men with less of knowledge about the disease.

Man's search for ideals of masculinity, such as being active, providing instead of being cared for, not expressing fragility, or taking care of himself, keeps him away from preventive examinations, giving him a greater exposure to risks (sexually transmissible diseases, neoplasias, cardiopathies, etc) and, therefore, leads to carelessness about his health. For men, the possibility of being ill and looking for a doctor could be viewed as assuming a passive role, dependent and fragile.

To be passive means to be penetrated. Metaphorically, women and homosexuals are the ones who are penetrated. The DRE cannot be seen as just a physical penetration and but can be associated, symbolically, as a violation and humiliation [25]. According to Gomes et al. [10] DRE does not touch only the prostate, but also touches and “scratches” the masculinity.

Many facts related to the sexual life and the genitals could be explained if it is related to the psycho-affective development. The “diagnostic labels” that people receive are stressors, mainly when negative stranger beliefs play a role, and these determine behaviors of fear of screening. We found that 40.94 % had felt some kind of fear.

Irrespective of being male or female, these feelings can delay seeking a diagnosis that may result in early detection and subsequent effective treatment. Thus the present fear impedes the desire for early PCa screening.

Lucumi-Cuesta and Cabrera-Arana [26] found a significant difference between the history of the DRE and schooling, socioeconomic status, health system coverage, perception of susceptibility to the disease, and perception of barriers and benefits of the examination. Also a significant difference was found between intent to submit to DRE and health insurance coverage, perception of severity of the disease and perception of barriers.

Factors involved in the low desire among African American men to be tested for PCa risk include their socio-demographic profile, past screening, perceived susceptibility and cognitive and psychosocial factors [27].

While it is expected that Black men with a family history of the disease might perceive their risk to be higher and consequently be more worried about getting PCa, and thus be more likely to accept cancer screening tests, this was not confirmed by Bloom et al. [28]. Men with a self-reported family history of PCa 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 DRE.

Meiser et al. [29] found in a cross-sectional study that psychological factors are the most important influence on men's acceptance of DRE, whereas external factors, including partner's involvement, influence the accomplishment of DRE.

An observational study conducted to identify sociocultural predictors of men's psychological reactions to PCa diagnoses found that there was no racial difference in the men's reaction. However, better awareness of illness stressors, temporal orientation, which determines management and organizational processes, and greater social pressure exert a positive effect on avoidance reactions, reducing the growth of negative thoughts. It highlights the need for individualized approaches to help men address their thoughts and feelings about being diagnosed with PCa. These efforts should include strategies that address cultural beliefs and values related to temporal orientation [30].

Cohen et al. [31] established an association between perceived risk of PCa, PCa specific worry, cancer related symptoms and PSA levels or findings from DRE in a large screened sample of 1635 men. The results suggest that PCa-specific worry was associated significantly with abnormal findings.

The worry or concern about PCa was associated with a significantly higher frequency of PCa screening; however age and family history did not modify the association between worry about PCa and frequent screening [32].

Although 85.47% of patients knew about the importance of DRE, 80.81% of them had felt better informed after the medical consultation. These data show the influence of the medical orientation where a poor understanding of referenced medical terms and low scholarship level could create barriers in the understanding of the examination results and in obtaining the assent for the treatment [33].

Woods et al. [34] states that a physician's aggressive, positive engagement in shared decision-making, tailored by social influences promoting prostate cancer prevention among Black men, as well as institutional screening policy, have the potential to increase early detection and reduce morbidity among this group. Poorly perceived knowledge of the disease, poor education level, low income, age (50 years old or more), cognitive and psychosocial perception, are the negative factors that influence the acceptance of PCa early detection in African American men [35,36].

The studied patients are a very select group of people, being men who have consulted an urologist, and data should not be extrapolated. While there is no validated questionnaire in this scenario, it is a study limitation and future efforts are necessary in this regard.

Access to information can be a factor in seeking an urologist and accomplishment of the DRE. However, this does not guarantee early detection. Emotional aspects play a significant role in this sphere. Debates on masculine sexuality are carried out in the media and they impact the behaviors of healthy young men.

Only the prevention of disease and conscious awareness of emotions and of their bodies can lead to an internal revolution in men and through this, to human evolution [37]. The understanding of human nature is essential in the development of educational campaigns. More research and public education are necessary, with informational campaigns addressing men's emotional attitudes, and emphasizing the importance of early detection for PCa. By changing perceptions, providing empathy, respect and focusing on the perception of the person's own body, it is possible that each individual could find his own way to a satisfactory way of living, resulting in a better quality of life [38].

Conclusions

Defensive emotional reactions to DRE that inhibit the search for early detection of PCa are baseless, and the majority of the patients found the procedure less awkward than they had imagined it would be and they would repeat the examination in the future.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.