title: A population-based study on the association between educational length, prostate-specific antigen testing and use of prostate biopsies.
abstract: OBJECTIVE
  The aim of this study was to determine whether educational length affects prostate-specific antigen (PSA) testing and the time to prostate biopsy for men with raised PSA values.
  
  
  METHODS
  Using register data on all men in Stockholm County in 2013 (n = 1,052,841), the limited-duration point prevalence of PSA testing and time between test and prostate biopsy or repeat testing were analysed. Patterns of follow-up were assessed using Kaplan-Meier product limit estimators and Cox proportional hazard models. Educational length was categorized as short (≤ 9 years), intermediate (10-12 years) or long (≥ 13 years).
  
  
  RESULTS
  PSA testing increased with educational length in all age groups. Among men aged 50-69 years, 61% with long and 54% with short education had had a PSA test within the preceding 10 years (p < 0.001). In men with PSA 4-10 ng/ml, 40% [95% confidence interval (CI) 38-41] with long and 27% (95% CI 26-29) with short education underwent a prostate biopsy within 12 months. After adjusting for PSA level and age, educational length was still associated with the chance of having a prostate biopsy in men with PSA 4-10 ng/ml (hazard ratio 1.22, 95% CI 1.12-1.31), but not in men with higher PSA values.
  
  
  CONCLUSIONS
  PSA testing increased with educational length. Men with long education were more likely to have a prostate biopsy after an increased PSA value below 10 ng/ml than men with short education. These differences may contribute to the worse prostate cancer outcomes observed among men with lower socioeconomic status.
authors.affiliation: a Department of Medical Epidemiology and Biostatistics , Karolinska Institutet , Stockholm , Sweden ;|b Department of Clinical Sciences at Danderyd Hospital , Karolinska Institutet , Stockholm , Sweden ;|c Department of Urology , Helen Diller Family Comprehensive Cancer Center, University of California , San Francisco , CA , USA ;
authors.forename: Tobias
authors.initials: T
authors.lastname: Nordström
authors.affiliation: d Urological Cancer Research Unit, Department of Translational Medicine , Lund University , Lund , Sweden ;|e Department of Urology , Cambridge University Hospitals , Cambridge , UK ;
authors.forename: Ola
authors.initials: O
authors.lastname: Bratt
authors.affiliation: d Urological Cancer Research Unit, Department of Translational Medicine , Lund University , Lund , Sweden ;
authors.forename: Joakim
authors.initials: J
authors.lastname: Örtegren
authors.affiliation: a Department of Medical Epidemiology and Biostatistics , Karolinska Institutet , Stockholm , Sweden ;
authors.forename: Markus
authors.initials: M
authors.lastname: Aly
authors.affiliation: f Karolinska Institutet , Department of Clinical Science, Intervention and Technology (CLINTEC) , Stockholm , Sweden ;|g Swedish Council for Health Technology Assessment , Stockholm , Sweden.
authors.forename: Jan
authors.initials: J
authors.lastname: Adolfsson
authors.affiliation: a Department of Medical Epidemiology and Biostatistics , Karolinska Institutet , Stockholm , Sweden ;
authors.forename: Henrik
authors.initials: H
authors.lastname: Grönberg
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy / Q000706:statistics & numerical data*; D004522:Educational Status; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011467:Prostate / Q000473:pathology; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000097:blood / Q000175:diagnosis* / Q000473:pathology; D013548:Sweden
chemical_list: D017430:Prostate-Specific Antigen
keywords: Diagnosis; epidemiology; population-based studies; prostate cancer; prostate-specific antigen (PSA); socioeconomic status