Prostate cancer is the most common cancer in the United States, with
an estimated 200,000 new cases diagnosed in 1998. Compared with
white men, African-American men have a 66% higher incidence of
prostate cancer and mortality rates twice as high.
Widespread use of PSA testing has led to a 50% increase in the
incidence of prostate cancer from 1989 to 1993, as well as an
increased frequency and proportion of early stage prostate cancer
diagnoses. There is, however, concern that improvements in care for
African-American men are not as great as for white men. Moreover,
there are debates whether these improvements in prostate cancer care
are associated with lower mortality. This lack of data about the
efficacy of prostate cancer screening has led to uncertainty over
whether routine PSA testing should be recommended for whites,
African-Americans, and other racial/ethnic minorities.
Barriers to Screening
While the debate over widespread use of PSA for routine prostate
cancer screening continues, it is apparent that there are many
economic and sociocultural barriers to screening. Moreover, these
barriers are likely to differ across racial/ethnic groups.[4-6]
For example, lack of access to screening and early detection programs
among African-American men is one factor associated with later stages
of prostate cancer at presentation. Also, African-American men with
low income may not be able to afford PSA screening, which is not
covered by Medicare. Finally, African-Americans often are reluctant
to participate in screening programs, because of concerns over the
Poor literacy skills are thought to be another potential factor in
explaining racial variations in medical care and outcomes for cancer
patients.[5,6] African-Americans with lower educational levels may
lack adequate knowledge of screening and early cancer detection
efforts. Educational materials about screening and early detection
are often written at a literacy level well above that of a
significant portion of the US population.
It is estimated that 48% of the adult US population have insufficient
literacy skills, with 23 million adults being functionally
illiterate. Among low income African-American men, the elderly are
particularly affected by low literacy
barriers. One study of low income minority individuals found an
81% prevalence of inadequate or marginal functional health literacy
among individuals who were over age 60, compared with 19% for those
aged 18 to 30.
We conducted a study to evaluate how the incidence of advanced stage
prostate cancer at presentation is associated with literacy skills
and race among low income older men. Our study population
consisted of 212 English-speaking men treated at prostate cancer
clinics in Chicago and Shreveport, Louisiana, over a 6-month period
in 1996 and 1997.
All of the Chicago patients were treated at the Chicago VA Healthcare
System/Lakeside Division, while two thirds of the Shreveport patients
were treated at the Overton-Brooke VA Medical Center, and one third
received care at a univer-sity hospital that provides care to low
income patients who are uninsured or who are covered by Medicaid.
Both health settings are part of equal access systems, treating
primarily low income patients.
We assessed patients literacy levels with a validated
instrument, the Rapid Estimate of Adult Literacy in Medicine
(REALM). The REALM is an individually administered medical word
recognition and pronunciation test, comprised of 66 words that
patients are expected to know in order to participate effectively in
their own health care. It was designed for evaluating adult reading
ability in the medical setting and is an indicator of functional
Raw REALM scores can be converted into four reading grade levels;
0-3rd grade, 4th-6th grade, 7th-8th grade, and 9th grade and above.
The REALM can be administered and scored in 1 to 3 minutes. In
addition to REALM scores, we obtained information from medical
records on patient age, race/ethnicity, and pathologic stage.
Of the 212 men in the study, 155 were from Shreveport and 57 from
Chicago. The mean age of the group was 70.8 years. Patients were
almost equally divided into two racial groups: African-American and
white. Patients varied in age, with 22.6% under 65 years of age,
45.8% between 65 and 74, and 31.6% age 75 or older.
Literacy differed by stage, race, and site of care, but not by age.
Men with metastatic cancer at presentation were 1.5 times more likely
to have lower literacy levels (39.6% of patients with stage D disease
had literacy levels of 6th grade or below vs 24.8% of stage A to C
patients, P < .001). African-American men were more likely to have
lower literacy levels (52.3% had levels of 6th grade or below vs 8.7%
of whites, P < .001).
When we evaluated predictors of late stage prostate cancer at
presentation, we found higher rates related to two factors: literacy
levels lower than 6th grade (54.5% vs 37.7%, P = .02) and
African-American race/ethnicity (49.5% vs 35.9%, P < .05).
City and older age were not significant univariate predictors of
advanced stage prostate cancer at presentation. However, in a
multivariate regression model (after adjustment for literacy level,
geographic location, and age), race was no longer a significant
predictor of advanced stage of disease at presentation (odds radio =
1.4; 95% CI = 0.7,2.7).
Race Not Significant Predictor
These results suggest that differences in literacy are likely to be
an important and often overlooked factor to consider when evaluating
differences in stage at presentation among different socioeconomic
and racial groups. In this study of low income older men, after
adjustment for differences in literacy levels, race was not a
significant predictor of advanced stage of prostate cancer at presentation.
Low literacy skills may be an important factor in explaining advanced
stage of prostate cancer at presentation for both white and
African-American men.[2,4-6] Low income, low literacy men may not be
aware of the possibility of undergoing prostate cancer screening and
the availability of screening programs at churches, schools, clinics,
county hospitals, and VA medical centers. Previous research has shown
that poor literacy skills are an important factor associated with low
usage of preventive health services and with knowledge and
understanding of an individuals medical illnesses.
Several aspects of this study should be highlighted. First, a
specific evaluation is required to assess literacy skills. The REALM
is an easily and rapidly administered test to formally assess
literacy. It has been shown that patient self-reports of
educational level are not a good indicator of literacy skills for
medical information. Patients are reluctant to admit to poor
reading skills and may not be familiar with medical terminology.
Moreover, standardized tests may overestimate a patients
ability to read and comprehend medical passages.[13-15]
Second, patients such as those in our study who are treated in equal
access health systems and have guaranteed financial access to care
may still face cultural, social, and personal barriers to medical care.
Relevance to Clinicians
The findings of this pilot study on medical literacy and prostate
cancer, as well as those of larger studies, are relevant to
practitioners.[7,16] Given that an estimated 48% of US adults have
insufficient literacy skills and that many, if not most, medical
educational materials are written at the high school or college
level, a large portion of patients may not understand this information.
Efforts to improve this situation include a randomized controlled
trial, initiated by ECOG, to evaluate low literacy consent forms in
the clinical trial setting. The Save our Sisters Projects for
increasing mammography use is an example of a program that includes
culturally appropriate, easily understandable educational materials.
Patient education is unlikely to be successful as a single
intervention. Medical information, written or audiovisual, must be
developed so as to be easily understood by patients, family members,
and peers. In addition, culturally sensitive, low literacy
educational materials, developed with the input of the target
population, may improve patient awareness of prostate cancer.
Ultimately, these interventions may lead to a decrease in the
incidence of advanced stage prostate cancer. w
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