Abstract
Background
Black individuals in the U.S. experience significantly higher prostate cancer mortality and are more likely to be diagnosed at younger ages with aggressive disease. This disparity may be influenced by negative healthcare perceptions and racial discordance between patients and providers, impacting lower rates of prostate-specific antigen (PSA) screening. We hypothesized that these factors would be associated with reduced PSA screening uptake, particularly among Black men.
Objectives
This study aimed to examine the association between negative healthcare perceptions and PSA screening, assess whether this relationship differs by race, and evaluate the role of racial discordance in influencing screening behavior.
Methods
We analyzed data from the 2018–2022 Medical Expenditure Panel Survey. The sample included 2373 men aged 45–70 who self-identified as non-Hispanic White or Black and had complete data on PSA screening, healthcare perceptions, and demographics. Negative healthcare perceptions were measured using a Health Perceptions Index (HePI), constructed from MEPS items (higher scores reflect more negative perceptions).
Results
Higher HePI scores were significantly associated with lower PSA screening rates (p < 0.01). Interaction models indicated that Black men with higher HePI scores were disproportionately less likely to undergo screening. Racial discordance with providers was independently associated with reduced screening likelihood (~10.2 percentage points; p < 0.01). Models including interaction terms (age, race, and discordance) showed that older Black men with high HePI scores and discordant providers were least likely to be screened.
Conclusions
PSA screening disparities are shaped by negative healthcare perceptions and racial discordance, particularly among older Black men. Addressing these barriers through culturally tailored education, improved workforce diversity, and strengthened provider–patient relationships may help close screening gaps. These findings highlight the relevance of healthcare system perceptions in understanding screening disparities and may inform future strategies to identify at-risk individuals.
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Data availability
The data used in this study are publicly available from the Medical Expenditure Panel Survey (MEPS) conducted by the Agency for Healthcare Research and Quality (AHRQ). MEPS data can be accessed at https://meps.ahrq.gov/mepsweb/. The code used for all analyses, including data cleaning, variable construction, and statistical modeling, will be publicly available at https://github.com/Saketh-Damera/HePI-PSA-Screening upon publication.
References
Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin. 2024;74:12–49.
Lowder D, Rizwan K, McColl C, Paparella A, Ittmann M, Mitsiades N, et al. Racial disparities in prostate cancer: a complex interplay between socioeconomic inequities and genomics. Cancer Lett. 2022;531:71–82.
Lillard JW, Moses KA, Mahal BA, George DJ. Racial disparities in Black men with prostate cancer: a literature review. Cancer. 2022;128:3787–95.
Dess RT, Hartman HE, Mahal BA, Soni PD, Jackson WC, Cooperberg MR, et al. Association of black race with prostate cancer–specific and other-cause mortality. JAMA Oncol. 2019;5:975.
Nemesure B, Scarbrough KH, Mermelstein L. Racial disparities in prostate cancer stage at diagnosis persist despite community affluence. Res Rep Urol. 2022;14:305–12.
Nyame YA, Gulati R, Heijnsdijk EAM, Tsodikov A, Mariotto AB, Gore JL, et al. The impact of intensifying prostate cancer screening in black men: a model-based analysis. JNCI J Natl Cancer Inst. 2021;113:1336–42.
Kensler KH, Pernar CH, Mahal BA, Nguyen PL, Trinh QD, Kibel AS, et al. Racial and ethnic variation in PSA testing and prostate cancer incidence following the 2012 USPSTF recommendation. J Natl Cancer Inst. 2021;113:719–26.
Qian Z, Alexander J, Daniels D, Abdollah F, Cole AP, Iyer HS, et al. Racial differences in postpandemic trends in prostate-specific antigen screening. JNCI Cancer Spectrum. 2024;8. Available from: https://academic.oup.com/jncics/article/doi/10.1093/jncics/pkae016/7636642.
LaVeist TA, Isaac LA, Williams KP. Mistrust of health care organizations is associated with underutilization of health services. Health Serv Res. 2009;44:2093–105.
Armstrong K, Ravenell KL, McMurphy S, Putt M. Racial/ethnic differences in physician distrust in the United States. Am J Public Health. 2007;97:1283–9.
Benjamins MR, Whitman S. Relationships between discrimination in health care and health care outcomes among four race/ethnic groups. J Behav Med. 2014;37:402–13.
Taber JM, Leyva B, Persoskie A. Why do people avoid medical care? A qualitative study using national data. J Gen Intern Med. 2015;30:290–7.
Hong YR, Tauscher J, Cardel M. Distrust in health care and cultural factors are associated with uptake of colorectal cancer screening in Hispanic and Asian Americans. Cancer. 2018;124:335–45.
Sadeq C. A comparison of Taylor linearization and balanced repeated replication methods for variance estimation in medical expenditure panel survey. Agency for Healthcare Research and Quality Working Papera. 2013. Available from: https://www.meps.ahrq.gov/data_files/publications/workingpapers/wp_13004.pdf.
Carter HB, Albertsen PC, Barry MJ, Etzioni R, Freedland SJ, Greene KL, et al. Early detection of prostate cancer: AUA guideline. J Urol. 2013;190:419–26.
DeSantis CE, Miller KD, Goding Sauer A, Jemal A, Siegel RL. Cancer statistics for African Americans, 2019. CA Cancer J Clin. 2019;69:211–33.
Carthon B, Sibold HC, Blee S D, Pentz R. Prostate cancer: community education and disparities in diagnosis and treatment. Oncologist. 2021;26:537–48.
Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118:293–302.
Lie DA, Lee-Rey E, Gomez A, Bereknyei S, Braddock CH. Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research. J Gen Intern Med. 2011;26:317–25.
Loeb S, Ravenell JE, Gomez SL, Borno HT, Siu K, Sanchez Nolasco T, et al. The effect of racial concordance on patient trust in online videos about prostate cancer: a randomized clinical trial. JAMA Netw Open. 2023;6:e2324395.
US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Bibbins-Domingo K, Caughey AB, et al. Screening for prostate cancer: US preventive services task force recommendation statement. JAMA. 2018;319:1901.
American Cancer Society. Prostate Cancer Early Detection, Diagnosis, and Staging. Cancer.org; 2023. Available from: https://www.cancer.org/content/dam/CRC/PDF/Public/8795.00.pdf.
Moses KA, Sprenkle PC, Bahler C, Box G, Carlsson SV, Catalona WJ, et al. NCCN Guidelines® insights: prostate cancer early detection, version 1.2023: featured updates to the NCCN guidelines. J Natl Compr Canc Netw. 2023;21:236–46.
Castillo EG, Ijadi-Maghsoodi R, Shadravan S, Moore E, Mensah MO, Docherty M, et al. Community interventions to promote mental health and social equity. Curr Psychiatry Rep. 2019;21:35.
Doubeni CA, Nelson D, Cohn EG, Paskett E, Asfaw SA, Sumar M, et al. Community engagement education in academic health centers, colleges, and universities. J Clin Transl Sci. 2022;6:e109.
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Authors and Affiliations
Contributions
SD conducted data cleaning, statistical analyses, interpretation, and drafted the initial manuscript. JRL contributed to data interpretation and manuscript editing. YRH advised on instrument design, statistical modeling, and interpretation of findings. YAN provided clinical expertise in prostate cancer screening and contributed to interpretation and manuscript revision. NH conceptualized the study, supervised the project, guided study design and analytic strategy, and provided revisions to the manuscript. All authors reviewed and approved the final version of the manuscript.
Corresponding author
Ethics declarations
Competing interests
YAN reports grants from the Department of Defense, National Institutes of Health (NIH), and the Andy Hill Cancer Research Endowment (CARE) Fund during the conduct of the study; personal fees from OrthoClinical Diagnostics and ImmunityBio Inc outside the submitted work. YRH reports serving as a consultant for WW International during the period this study was conducted. No disclosures were reported by the other authors. The authors have no conflicts of interest to report.
Ethics approval and consent to participate
This study was designated as non-human subjects research by the University of Florida Institutional Review Board, since it used publicly available, de-identified data from the Medical Expenditure Panel Survey. Therefore, informed consent and full institutional approval were not required. All methods were performed in accordance with relevant guidelines and regulations.
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Damera, S., Lee, J.R., Hong, YR. et al. Negative perceptions of the health system and racial inequities in PSA screening. Prostate Cancer Prostatic Dis (2025). https://doi.org/10.1038/s41391-025-01044-w
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DOI: https://doi.org/10.1038/s41391-025-01044-w
