Multilevel Small Area Estimation of Prostate-specific Antigen Screening Test in the United States by Age Group

2018 Behavioral Risk Factor Surveillance System

Zahava Berkowitz, MSPH, MSc; Xingyou Zhang, PhD; Thomas B. Richards, MD; Susan A. Sabatino, MD, MPH; Lucy A. Peipins, PhD; Judith Lee Smith, PhD


J Am Board Fam Med. 2021;34(3):634-647. 

In This Article

Abstract and Introduction


Background: In 2018, the US Preventive Services Task Force (USPSTF) recommended prostate cancer screening for men aged 55 to 69 years who express a preference for being screened after being informed about and understanding prostate-specific antigen (PSA) test benefits and risks. USPSTF recommended against screening men aged ≥70 years. We aim to generate county-level prevalence estimates, masked by national and state estimates, to identify counties with high PSA screening prevalence.

Methods: We fitted multilevel logistic regression mixed models for 4 age groups (≥40, 40 to 54, 55 to 69, ≥70 years), using data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 116,654) and other sources. We evaluated consistency between our model-based state and BRFSS direct state estimates with Spearman and Pearson correlation coefficients.

Results: PSA screening prevalence increased with increasing age groups: 7.7% for men aged 40 to 54 years, 27.2% for men aged 55 to 69 years, and 33.7% among men age ≥70 years, and was largely clustered in the South and Appalachia. Many county estimates among men aged ≥70 years exceeded 40%, especially in the South. Correlation coefficients were 0.94 for men aged ≥40, and ≥0.85 for men aged 40 to 54 years, 55 to 69 years, and ≥70 years.

Conclusions: PSA screening was highest among men ≥70 years, for whom it is not recommended, and in the South among all age groups. Screening varied substantially within states.

Impact: In 2018, on average, more than 1 in 4 men aged 55 to 69 years and 1 in 3 men aged ≥70 years underwent PSA screening in the prior year, suggesting potential overuse among some men.


In 2008, the US Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA) screening test for prostate cancer for men aged 75 years or older,[1] and in 2012, the USPSTF recommended against PSA screening for men of all ages.[2] In 2018, the USPSTF recommended that men should be informed about and understand the benefits and harms of screening and express a preference to be screened before the test is offered.[3,4] This current recommendation is limited to men aged 55 to 69 years, for whom the net benefits might be small (Grade C recommendation, selective offering). For men aged ≥70 years, the USPSTF recommended against PSA screening (Grade D, discourage use), stating that the potential benefits do not outweigh the harms.[4] Potential harms include false positives, overdiagnosis and overtreatment, and treatment complications, such as loss of normal urinary, bowel, and sexual functions.[3] The USPSTF was not able to provide specific recommendations for men aged <55 years, for men with family history, or African-American men, who have increased risk of prostate cancer mortality.[5,6] Although screening might offer potential benefits to some men among the youngest and oldest age groups, screening might also expose these men to adverse effects.[4] PSA screening has been associated with disproportionate cost among men aged 70 years or older.[7]

Currently few publications review geospatial variations in PSA screening in the United States. Although recent studies identified predictors associated with PSA screening, few have described variations among states or US Census regions.[8–12] National, regional and state-level estimates can mask the variations in PSA screening within states.[13] Previous analyses of breast and colorectal cancer screening[14,15] found large variations between and within states with striking geographical distributions. To improve knowledge of PSA screening in smaller areas, we performed a county-level analysis to describe the prevalence of PSA screening by county, and by age groups for whom USPSTF conclusions varied. Small area estimates (SAE) can help identify areas of frequent screening, especially among men aged 70 or older for some of whom screening could reflect overuse. Estimates may also inform public health research, programmatic, and communication efforts.