Determinants of Prostate Cancer Screening in Korean Men: A Nationwide Study Using the Korean National Cancer Screening Survey 2023
Article information
Abstract
Purpose
Research on the prevalence of prostate cancer (PCa) screening and reasons for undergoing screening is limited. We aimed to identify the factors influencing PCa screening behavior and explore the underlying motivations among Korean men.
Materials and Methods
This cross-sectional study used data from the 2023 Korean National Cancer Screening Survey, which employs a nationally representative random sampling method. This study included 1,784 men aged 40-74 years. The respondents reported their experiences with PCa screening. Multivariable logistic regression analysis was conducted to identify the factors associated with participation in PCa screening.
Results
The lifetime PCa screening rate was 18.6%. Among screening modalities, transrectal ultrasonography was the most frequently used (31.9%), followed by prostate-specific antigen tests (25.6%) and digital rectal examinations (21.5%). The multivariable analysis identified several factors that significantly increased the likelihood of screening participation, including older age, living with a spouse, poor self-reported health, and abstinence from alcohol consumption in the previous 12 months. Men who had undergone colorectal cancer screening were more likely to participate in PCa screening (adjusted odds ratio, 4.01; 95% confidence interval, 2.03 to 7.93) than those who had not. The primary motivations for screening were recommendations from family or social networks (31.9%) and inclusion in health examination packages (24.3%), whereas healthcare provider recommendations (18%) and symptomatic concerns (5.7%) were the least influential.
Conclusion
Our findings highlight the importance of providing evidence-based information for PCa screening recommendations and the need for improved communication and implementation of a shared decision-making approach for PCa screening in Korea.
Introduction
Prostate cancer (PCa) occupies a prominent position in global and Korean male cancer epidemiology, ranking as the second most prevalent malignancy worldwide and the fourth most common cancer among Korean men in 2022 [1]. Between 2000 and 2020, the crude death rate for PCa increased substantially, rising from 1.2 to 4.3 per 100,000 individuals, establishing PCa as the leading cause of mortality among urological malignancies [2]. Additionally, demographic projections for Korea indicate a significant shift toward an aging population [3]. This demographic transition is expected to have profound implications for PCa epidemiology in Korea, given the well-established association between advanced age and PCa risk [2,4-6]. Projections suggest that by 2034, PCa will become the second most frequently diagnosed malignancy among Korean men, following lung cancer, and will surpass the incidence rates of both colorectal and stomach cancers [3].
In 2018, the U.S. Preventive Services Task Force (USPSTF) guidelines recommended that men aged 55-69 years engage in shared decision-making (SDM) with healthcare providers regarding prostate-specific antigen (PSA) screening for PCa. This process should precede any individualized screening decision, considering the potential benefits and harms [7]. In 2023, the American Urological Association (AUA) updated its guidelines recommending that clinicians should offer PSA-based PCa screening to men aged 45-50 years, emphasizing SDM [8]. This marks a shift to a younger age range compared with the 2013 guidelines, which focused on men aged 55-69 years. The selection of screening modalities, such as PSA testing, digital rectal examination (DRE), and magnetic resonance imaging, continues to be debated because of the different advantages and disadvantages associated with each [9-14].
Currently, the National Cancer Screening Program in Korea does not include PCa and recommends screening only for stomach, colon, lung, liver, breast, and cervical cancers. PCa screening is often considered an opportunistic screening method. Comprehensive health examination packages typically include various tests and screenings with PCa screening options such as PSA tests, transrectal ultrasonography, and DRE. However, research on the prevalence of PCa screening and reasons for undergoing screening is lacking. Although some studies have examined the factors affecting PCa screening behavior in Korean men, they have not comprehensively addressed the range of screening modalities and motivations [15,16]. Thus, this study was conducted to provide insights into PCa screening trends in Korea, as specific data on how many men receive PCa screenings and their motivations for doing so are limited. We aimed to identify the factors influencing PCa screening behavior and explore the underlying motivations of the Korean population.
Materials and Methods
1. Study source
We used data from the 2023 Korean National Cancer Screening Survey (KNCSS), which has been conducted annually to evaluate cancer screening participation rates and their associated determinants among Korean adults. The survey’s demographic focus encompasses men aged 40-74 years and women aged 20-74 years, aligning with the age-specific recommendations for the six malignancies included in the Republic of Korea’s National Cancer Screening Program. To ensure national representativeness, the KNCSS uses a stratified multistage sampling design based on population data categorized by region, age, and sex, as provided by the National Statistical Office of Korea. Data were collected through face-to-face interviews conducted by specialized survey agencies.
The recruitment process involved repeated household visits, with a maximum of three contact attempts per residence. One eligible individual was selected from each household. Explanations were provided to all participants, and informed consent was obtained before they participated in the survey. Previous studies have provided comprehensive details regarding the sampling methods [17,18].
Among the 4,500 participants in the 2023 KNCSS, we specifically included male participants aged 40-74 years to examine PCa screening practices.
2. Measurements/questionnaires
The screening status and modalities for PCa screening were determined using a structured questionnaire. The participants provided information on sociodemographic factors and history of PCa screening. The questions included “Have you ever undergone PCa screening?” and “What screening method have you experienced?” (with multiple options). For screening intervals, the participants were asked, “When was your last PCa screening using this method?” To identify the main motivation for PCa screening, the participants were asked, “What motivated you to undergo PCa screening?” Lifetime screening was defined as having undergone PCa screening at least once. Residential areas were categorized into metropolitan, urban, and rural regions based on provincial administrative divisions, as detailed in a previous study [19].
We considered several key sociodemographic factors. These included age groups (40-49, 50-59, 60-69, and 70-74 years), marital status (with or without a spouse), education level (secondary school graduate or lower, high school graduate, and university graduate or higher), monthly household income (≤ 3,000,000 KRW; 3,000,000-4,490,000 KRW; ≥ 4,500,000 KRW), private insurance status, self-reported health status (poor, average, and good), smoking status (non-smoker, former smoker, and current smoker), alcohol consumption in the past 12 months, body mass index (≤ 22.9 kg/m2, 23-24.9 kg/m2, and ≥ 25 kg/m2), family history of any type of cancer, and lifetime participation in colorectal cancer screening.
3. Statistical analysis
This study provides a descriptive analysis of PCa screening behaviors using frequencies and percentages to examine their relationship with various sociodemographic and health-related factors, such as age, marital status, education, income, insurance status, and health behaviors. Cancer screening rates were adjusted using the survey sample weights. Associations between categorical variables and PCa screening were assessed using the chi-square test. Two-stage regression analyses, including univariate and multivariable logistic regression, were performed to identify the factors significantly associated with participation in PCa screening. Statistical significance was set at p < 0.05. All analyses were performed using SAS ver. 9.4 (SAS Institute Inc.).
Results
In total, 1,784 individuals were included in the study. Among the 1,784 men, 18.6% underwent PCa screening (Table 1). High screening rates were found in men aged 70-74 years (42.3%), those reporting poor health (44.8%), those living with a spouse (19.4%), those with lower education levels (23.6%), and those with a monthly income of ≤ 3,000,000 KRW (23.2%). Former smokers (23.6%) and men who had abstained from alcohol consumption in the past 12 months (25.4%) also had high screening rates. Additionally, men with a family history of cancer had an increased likelihood of undergoing PCa screening (25.4%).
Characteristics of participants based on prostate cancer screening (n=1,784)
A significantly strong positive correlation was observed between screening rates for PCa and colorectal cancer (r=0.66, p < 0.001) (Fig. 1).
Correlation between prostate cancer screening rate and colorectal cancer screening rate. Each dot represents a specific age.
Among 333 men who reported undergoing PCa screening, only 12.3% underwent their most recent screening within the past year (Table 2). In contrast, approximately half (49.6%) of the participants reported that their last PCa screening was > 2 years before the survey. Transrectal ultrasound (TRUS) was the most frequently reported screening modality (31.9%), followed by PSA testing (25.6%) and DRE (21.5%). Abdominal computed tomography was relatively less common, accounting for 17.5% of screenings, whereas prostate magnetic resonance imaging was the least common (3.3%). The prevalence of PSA-based screening was 7.1%. Among the 333 men screened, only 15 were advised to undergo additional tests, with TRUS (47.1%) and PSA testing (35.3%) being the most commonly recommended follow-up examinations. Recommendations from family, relatives, or social circles (31.9%) and comprehensive health examination packages (24.3%) were significant motivators for screening participation. In contrast, healthcare provider recommendations and PCa symptoms were relatively less influential, motivating 18% and 5.7% of the participants, respectively.
Prostate cancer screening history and motivations
We conducted univariate and multivariable logistic regression analyses to identify the factors associated with participation in PCa screening (Table 3). Men aged 50-59 (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.75 to 4.12), 60-69 (aOR, 5.77; 95% CI, 3.62 to 9.20), and 70-74 (aOR, 13.94; 95% CI, 7.52 to 25.86) years were significantly more likely to undergo PCa screening than men aged 40-49 years. Men living with a spouse were more likely to undergo screening (aOR, 1.87; 95% CI, 1.07 to 3.26) than those without a spouse. Additionally, men with a university degree or higher (aOR, 2.52; 95% CI, 1.39 to 4.56) had greater odds of undergoing PCa screening than those with lower educational levels. Health status and lifestyle factors were also significantly associated with PCa screening. Men who rated their health as average or poor and those who reported abstaining from alcohol consumption in the past year demonstrated an increased likelihood of undergoing PCa screening. Moreover, a significant association was observed between colorectal cancer screening and PCa screening; men who had undergone colorectal cancer screening (aOR, 4.01; 95% CI, 2.03 to 7.93) were considerably more likely to be screened for PCa than those who had not been screened for colorectal cancer.
Associations between characteristics of participants and prostate cancer screening (n=1,784)
Discussion
In this study, we aimed to assess the PCa screening rate among Korean men aged 40-74 years and identify factors associated with screening behavior. Our findings indicated that approximately 18.6% of participants in this age group underwent PCa screening. The prevalence of PSA-based screening was 7.1%. This rate is lower than that reported in previous studies. Data from the 2016 National Health Insurance Services showed an overall PSA test rate of 7.27%, and an online survey by The Korean Urological Oncology Society reported a PSA-based screening rate of 16.7% [20,21]. Furthermore, the PCa screening rate in our study remained below that reported in other developed nations, including the United States and several European countries [22-24]. Comparing PCa screening rates across countries and studies is inherently challenging because of differences in study methodologies, including variations in the use of questionnaires and the predominant reliance on PSA testing alone in most studies as opposed to the use of multiple screening modalities in our study.
This study showed that PCa screening was prevalent among older men, particularly among those aged 70-74 years. This finding is consistent with the results of previous studies showing that the likelihood of undergoing PCa screening increases with age [21,23,25,26]. Other factors associated with an increased frequency of PCa screening included living with a spouse, reporting average or poor health status, and having a university degree or higher education. In contrast, men who consumed alcohol in the past 12 months were relatively less likely to undergo PCa screening.
Univariate and multivariable analyses yielded different results regarding the association between education level and participation in PCa screening. In the univariate analysis, men with a university degree or higher education had lower odds of undergoing PCa screening (OR, 0.61; 95% CI, 0.39 to 0.94) than those with lower education. However, after adjusting for potential confounding variables in the multivariable logistic regression model, these men had higher odds of participating in PCa screening (aOR, 2.52; 95% CI, 1.39 to 4.56). This apparent discrepancy can largely be attributed to the confounding effect of age on education level. Specifically, men in the 70-74 years age group who showed the highest likelihood of undergoing PCa screening were likely to have lower levels of education. Thus, age acted as a confounder, initially masking the positive association between higher education level and participation in PCa screening.
Individuals who had undergone colorectal cancer screening were significantly more likely to undergo PCa screening (aOR, 4.01; 95% CI, 2.03 to 7.93) than those who had not undergone colorectal cancer screening. This finding is consistent with those of previous studies that explored the relationship between colorectal cancer screening uptake and PSA-based PCa screening [25,27]. This correlation suggests that individuals who engage in one type of cancer screening are likely to participate in other screening behaviors. The higher likelihood of undergoing PCa screening among those who attend colorectal cancer screenings presents both opportunities and challenges. On the one hand, it may facilitate early detection in high-risk individuals; on the other hand, it highlights the need for clear communication regarding the differing recommendations for these two cancer types. Given the observed correlation between colorectal cancer and PCa screening behaviors, healthcare providers should leverage these opportunities to offer risk-stratified counseling for PCa screening in accordance with current guidelines [7,8].
The current USPSTF and AUA guidelines emphasize the importance of informed decision-making for PSA-based screening, considering the potential benefits and risks associated with the procedure. In alignment with this emphasis, a recent study conducted in 2023 investigated the effectiveness of web-based decision aids for PCa screening in Korea, highlighting the potential clinical significance of the decision-making process [28]. Despite these guideline recommendations and emerging research, our study revealed that only 18% of participants who underwent screening did so based on recommendations from healthcare providers. This low percentage suggests a potential communication gap between providers and patients regarding PCa screenings. However, this figure alone does not fully capture how physicians communicate these recommendations to participants. Therefore, it is crucial to assess the current implementation, effectiveness, and challenges of SDM for PCa screening in Korea. Additionally, physicians’ competencies in facilitating this process must be evaluated to ensure that patients are adequately informed and supported in making decisions regarding screening options.
Our study has several limitations. First, the cross-sectional design prevented determination of the direction of causal relationships between PCa screening and other factors. Second, our reliance on self-reported data, despite standardized interviewer training, may have introduced a recall bias. Third, we were unable to include family history of PCa in our analysis because of the limited number of participants. This limitation is particularly salient, given the recent USPSTF guidelines from 2018, which advocate for a risk-stratified approach to PCa screening, emphasizing factors such as racial background and family history [7]. Furthermore, in 2023, the AUA expanded its recommendations, advising clinicians to offer PCa screening beginning at ages 40-45 years for high-risk men, specifically those of African descent, carriers of specific genetic mutations, and individuals with a strong family history of PCa [8]. Therefore, exclusion of family history data from our analysis limited our ability to comprehensively evaluate this potentially significant determinant of participation in PCa screening. This omission may have implications for the complete interpretation of the factors influencing screening behaviors in our study population.
Nevertheless, this study offers an up-to-date and comprehensive analysis of PCa screening rates and associated factors using data from the 2023 KNCSS. This study makes a significant contribution to the body of research in Korea by examining the motivating factors that influence individuals undergoing PCa screening. Further studies focusing on Korean men’s knowledge of and attitudes toward PCa screening, particularly their awareness of the associated risks, potential benefits, and relevant risk factors, are warranted. Such research will be instrumental in informing the development and implementation of targeted educational initiatives for PCa screening. These efforts will enhance the effectiveness of screening practices and improve physician–patient communication, ultimately leading to better health outcomes through informed decision-making and risk-stratified screening approaches.
Notes
Ethical Statement
The study protocol was approved by the National Cancer Center Institutional Review Board of Korea (approval number: NCC20220356). All participants consented to participate in the survey for public benefit.
Author Contributions
Conceived and designed the analysis: Nguyen GV, Kang E, Suh M, Jun JK, Choi KS.
Collected the data: Lee HJ, Kang E.
Contributed data or analysis tools: Lee HJ, Kang E, Suh M, Jun JK, Choi KS.
Performed the analysis: Nguyen GV, Lee K.
Wrote the paper: Choi KS.
Conflict of Interest
Conflict of interest relevant to this article was not reported.
Acknowledgments
This study was supported by a Grant-in-Aid for Cancer Research and Control from the National Cancer Center of Korea (#2210772).