Impact of social and medical factors on routine clinical practice in prostate exams of asymptomatic males

Objectives: To examine routine clinical practice in prostate health exams in asymptomatic males, and to identify which factors influence it.

Materials and methods: Multicentre cross-sectional study in 1068 asymptomatic men aged 51-72. Groups: GA (n = 518): urban areas; GB (n = 550): rural areas. GA subgroups: GA1 (n = 364): prostate specific antigen (PSA) measured; GA2 (n = 154): PSA not measured. GB subgroups: GB1 (n = 346): PSA measured; GB2 (n = 204): PSA not measured. Variables: age, body mass index (BMI), digital rectal examination (DRE), PSA, prostate diagnosis, eating habits, physical exercise, marital status, number of children, occupational status, working hours, concomitant diseases and conditions, family history, attending physician. Descriptive statistics, Student's t-test, chi-square test, Fisher's exact test, ANOVA, Pearson and Spearman correlations were used.

Results: Mean age 62.3 years (standard deviation: SD 5.12). Age in GA (60.89, SD 5.53) was lower than in GB (65.10, SD 5.03); age was higher in GA1 (61.22, SD 5.49) than in GA2 (59.04, SD 5.37). There was no difference in BMI between GA and GB. DRE: No exams were performed without prior PSA. No DRE were performed in GA; 11 (3.18%) were performed in GB1. GA1: 53 had PSA > 4 ng/mL, of whom 28 had no prostate disease, 17 had benign prostatic hyperplasia (BPH) and 8 had prostate cancer (PCa). PCa prevalence in men with PSA > 4 ng/mL was 9.24% in GA and 5.19% in GB. GA1: higher PSA was correlated with lower BMI, lower age, higher occupational status, and morning shifts; lower PSA was correlated with higher alcohol consumption; older patients worked shifts and consumed more alcohol; men with higher occupational status consumed less alcohol; more men were married in GA1 (n = 343, [94.23%]) than in GA2 (n = 100, [64.93%]). In GA1, there were more non-smoking men (n = 291, [80.11%]) and men who smoked < 5 cigarettes/day (n = 23, [6.37%]), 6-10 cigarettes/day (n = 15, [4.05%]), and 11.20 cigarettes/day (n = 27, [7.33%]) than in GA2. Older men and men with higher occupational status consumed fewer cigarettes. Men who worked rotating shifts smoked more. There was no relationship between smoking and PSA level. There were more university-educated men in GA (n = 309, [59.65%]) than in GB (n = 110, [20%]). More men did not take physical exercise in GA2 (n = 49, [31.81%]) than in GA1 (n = 75, [23.90%]). GB1: PSA > 4 ng/mL in 89 patients, of whom 32 had PCa; younger men had higher PSA. PSA was higher in GB1 (mean 18.95 ng/mL, SD 12.93) than in GA1 (mean 1.61, SD 1.63). Men in GB ate more fast food than GA, with no difference between GA1 and GA2, or between GB1 and GB2. In GA there was variability in approach among the attending physicians; in GB there was no variability among attending physicians.

Conclusions: PSA tests are routinely given to 70.27% of asymptomatic men who consult a doctor in urban environments and to 62.09% of men in rural environments. In urban areas, the decision is affected by the preferences of the attending physician and by whether the patient is married. Occupational category, working hours and educational level have no impact. The decision to undergo a prostate health exam is associated with healthy habits such as physical exercise. No relationship was found between prostate disorders in asymptomatic men and high BMI, dyslipidemia or diet.

PSA; Benign prostatic hyperplasia; Medical factors; PCa factors; Prostate cancer

[1] Gravas S, Cornu JN, Gacci M, Gratzke C, Herrmann TRW, Mamoulakis C, et al. EAU Guidelines Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). ©European-Association-of-Urology-2020. 2020.

[2] Bonkat G, Bartoletti R, Bruyère F, Cai T, Geerlings SE, Köves B, et al. EAU Guidelines on Urological Infections. EAU Guidelines on Urological Infections. 2020; 65.

[3] Mottet N, Cornford P, van-den-Bergh RCN, Briers E, De-Santis M, Fanti S, et al. EAU - EANM - ESTRO - ESUR - SIOG Guidelines on Prostate Cancer. European Association of Urology Guidelines. 2020; edn. presented at the EAU Annual Congress Amsterdam. 2020.

[4] Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International Journal of Cancer. 2015; 136: E359-E386.

[5] Padilla-Fernández B-Y. Prostate tumor (pp. 637-655). In: Lorenzo-Gómez M.-F., Macias-Nuñez J.-F. (Eds.) Nefrourología, Cervantes Internacional. Cervantes Salamanca, España., Salamanca, España. 2013.

[6] Wolters-Kluwer. Clasificación profesional. Guias Juridicas. 2016.

[7] Gobierno-de-España, Real Decreto 184/2015, de 13 de marzo, which regulates the homogeneous catalog of equivalences of the professional categories of statutory health services personnel and the procedure for updating them, in: Ministerio de Sanidad S.S.e.I.D.G.d.S.P., Calidad e Innovación (p. 29447 a 29461). Subdirección General de Información Sanitaria y Evaluación (Ed.) Ministerio de Sanidad, Servicios Sociales e Igualdad. Dirección General de Salud Pública, Calidad e Innovación. Subdirección General de Información Sanitaria y Evaluación, Madrid, España, 2015. (In Spanish)

[8] Sanda MG, Beaty TH, Stutzman RE, Childs B, Walsh PC. Genetic susceptibility of benign prostatic hyperplasia. Journal of Urology. 1994; 152: 115-119.

[9] Miguel EDS, Lopes SO, Araújo SP, Priore SE, Alfenas RDCG, Herms-dorff HHM. Association between food insecurity and cardiometabolic risk in adults and the elderly: a systematic review. Journal of Global Health. 2020; 10: 020402.

[10] Parsons J. Lifestyle factors, benign prostatic hyperplasia, and lower urinary tract symptoms. Current Opinion in Urology. 2011; 21: 1-4.

[11] Bushman W. Etiología, epidemiología e historia natural. En Hiper-plasia prostática benigna y síntomas de las vías urinarias inferiores. Urologic Clinics of North America. 2009; 36: 403-415. (In Spanish)

[12] Meigs J, Mohr B, Barry M, Collins M, McKinlay J. Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men. Journal of Clinical Epidemiology. 2011; 54: 935-944.

[13] Kang D, Andriole GL, van de Vooren RC, Crawford D, Chia D, Urban DA, et al. Risk behaviours and benign prostatic hyperplasia. BJU International. 2004; 93: 1241-1245.

[14] Gass R. Benign prostatic hyperplasia: the opposite effects of alcohol and coffee intake. BJU International. 2002; 90: 649-654.

[15] Platz EA, Rimm EB, Kawachi I, Colditz GA, Stampfer MJ, Willett WC, et al. Alcohol consumption, cigarette smoking, and risk of benign prostatic hyperplasia. American Journal of Epidemiology. 1999; 149: 106-115.

[16] Press DJ, Pierce B, Lauderdale DS, Aschebrook-Kilfoy B, Lin Gomez S, Hedeker D, et al. Tobacco and marijuana use and their association with serum prostate-specific antigen levels among African American men in Chicago. Preventive Medicine Reports. 2020; 20: 101174.

[17] Kristal AR, Arnold KB, Schenk JM, Neuhouser ML, Goodman P, Penson DF, et al. Dietary patterns, supplement use, and the risk of symptomatic benign prostatic hyperplasia: results from the prostate cancer prevention trial. American Journal of Epidemiology. 2008; 167: 925-934.

[18] Bravi F, Bosetti C, Dal Maso L, Talamini R, Montella M, Negri E, et al. Food groups and risk of benign prostatic hyperplasia. Urology. 2006; 67: 73-79.

[19] Fritschi L, Glass DC, Tabrizi JS, Leavy JE, Ambrosini GL. Occupational risk factors for prostate cancer and benign prostatic hyperplasia: a case-control study in Western Australia. Occupational and Environmental Medicine. 2007; 64: 60-65.

[20] Salvatierra-Pérez C, Gil-Vicente A, Lorenzo-Gómez M, Hiperplasia benigna de Próstata (pp. 757-787). In: Lorenzo-Gomez M.-F., Macías-Núñez J.-F. (Eds.) Nefrourología, Salamanca (Spain), 2013.

[21] Reza HS, Ali Z, Tara H, Ali B. Age-specific reference ranges of prostate-specific antigen in the elderly of Amirkola: A population-based study. Asian Journal of Urology. 2020 (in press).

[22] Bonn SE, Sjölander A, Tillander A, Wiklund F, Grönberg H, Bälter K. Body mass index in relation to serum prostate-specific antigen levels and prostate cancer risk. International Journal of Cancer. 2016; 139: 50-57.

[23] Pickles K, Carter SM, Rychetnik L. Doctors’ approaches to PSA testing and overdiagnosis in primary healthcare: a qualitative study. BMJ Open. 2015; 5: e006367-e006367.

[24] Padilla-Fernández B, Lorenzo-Gómez M, Silva-Abuín J, Antúnez-Plaza P, Gil-Vicente Á. Importance of digital rectal examination for prostate cancer diagnosis. , in: Health I.S.o.M.s. (Ed.) Men´s Health World Congress, International Society of Men´s Health, Viena, Austria. 2011.

[25] Partin A, Yoo J, Carter H. The use of prostate-specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. Journal of Urology. 1993; 150: 110.

[26] Gerber G, Chodak G. Digital rectal examination in the early detection of prostate cancer. Urologic Clinics of North America. 1990; 17: 739-745.

[27] Yu E, Hahn W. Genetic alterations in prostate cancer. Clinical Genitourinary Cancer. 2005; 3: 220-229.

[28] Álvarez-Dardet C, Bolúmar F, García-Benavides F. Early detection of diseases. Medicina Clínica. 1989; 93: 221-225. (In Spanish)

[29] Brett T. An analisis of digital rectal examination and serum-orstate-specific antigen in the çearly detection pf prostate cancer in general practice. Family Practice. 1998; 15: 529-533.

[30] Castillejo MM, López FP, Coello DA, Rpca JM. Update on prevention and treatment of prostate cancer. Atención Primaria 2002; 30: 57-63. (In Spanish)

[31] Schroder FH, Roobol-Bouts M, Vis AN, van der Kwast T, Kranse R. Prostate-specific antigen-based early detection of prostate cancer-validation of screening without rectal examination. Urology. 2001; 57: 83-90.

[32] Lorenzo-Gomez M-F. BASES DE LA HORMONOTERAPIA EN EL CÁNCER DE PRÓSTATA AVANZADO. ENSAYOS CLÍNICOS. Salamanca, España: UNIVERSIDAD DE SALAMANCA©&Asociación Española de Urología©. 2017.

[33] Pérez-Cano E. Diagnostic situation of prostate cancer in Primary Heath Care. Primary Heath Care. Atención Primaria. 2000; 25: 27-35. (In Spanish)