title: Association between literacy, compliance with prostate cancer screening, and cancer aggressiveness: results from a Brazilian screening study.
abstract: OBJECTIVE
  Little is known about the effects of literacy levels on prostate cancer screening. This study evaluates the association between literacy, compliance with screening, and biopsy findings in a large Brazilian screening study.
  
  
  METHODS
  We analyzed 17,571 men screened for PCa with digital rectal examination (DRE) and total and free prostate-specific antigen (PSA) from January 2004 to December 2007. Of those, 17,558 men had information regarding literate status. Full urological evaluation in a specialized cancer center was recommended in the case of: a) suspicious DRE, b) PSA > 4.0 ng/mL, or c) PSA 2.5-3.9 ng/mL and free/total PSA (f/tPSA) ratio 15%. Transrectal ultrasound guided prostate biopsy (14 cores) was performed upon confirmation of these findings after the patient's consent. Patients' compliance with screening recommendations and biopsy results were evaluated according to literacy levels.
  
  
  RESULTS
  an abnormal PSA, a suspicious DRE, or both were present in 73.2%, 19.7%, and 7.1% of those men who underwent biopsy, respectively. PCa was diagnosed in 652 men (3.7%). Previous PSAs or DREs were less common among illiterate men (p < 0.0001). Additionally, illiterate men were less prone to attend to further evaluations due to an abnormal PSA or DRE (p < 0.0001). PSA levels > 10 mg/mL (p = 0.03), clinical stage > T2a (p = 0.005), and biopsy Gleason > 7 (p = 0.02) were more common among illiterate men.
  
  
  CONCLUSIONS
  In a screened population, literacy levels were associated with prior PCa evaluations and with compliance with screening protocols. Illiterate men were at higher risk of being diagnosed with more advanced and aggressive PCa.
authors.affiliation: Department of Urology, Faculdade de Medicina do ABC, Brazil.
authors.forename: Marcos
authors.initials: M
authors.lastname: Tobias-Machado
authors.forename: Gustavo F
authors.initials: GF
authors.lastname: Carvalhal
authors.forename: Celso H
authors.initials: CH
authors.lastname: Freitas
authors.forename: Rodolfo B dos
authors.initials: RB
authors.lastname: Reis
authors.forename: Leonardo O
authors.initials: LO
authors.lastname: Reis
authors.forename: Lucas
authors.initials: L
authors.lastname: Nogueira
authors.forename: Roberto D
authors.initials: RD
authors.lastname: Machado
authors.forename: Wesley
authors.initials: W
authors.lastname: Magnabosco
authors.forename: René A C
authors.initials: RA
authors.lastname: Vieira
authors.forename: Edmundo C
authors.initials: EC
authors.lastname: Mauad
authors.forename: André L
authors.initials: AL
authors.lastname: Carvalho
authors.forename: Eliney F
authors.initials: EF
authors.lastname: Faria
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D001938:Brazil; D051517:Digital Rectal Examination; D004522:Educational Status; D057220:Health Literacy; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D060787:Neoplasm Grading; D011237:Predictive Value of Tests; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000473:pathology; D012307:Risk Factors
chemical_list: D017430:Prostate-Specific Antigen