The study, published in the journal Cancer Causes & Control, was led by Neill Bates of the Department of Academic Affairs at the Brody School of Medicine at East Carolina University, together with urologist Michael Blute Jr., epidemiologist Dmitry Tumin, and family physician Parker Barnwell Jr. The research team set out to answer a deceptively simple question: after the US Preventive Services Task Force issued its landmark 2018 guideline recommending that men aged 55 to 69 make individualized decisions about PSA screening through shared decision-making with their clinicians, did rural and urban men in the eligible age range end up receiving the test and participating in those discussions at comparable rates? The question matters because the 2018 guideline made the screening decision fundamentally conversational rather than automatic, and any barrier to meaningful patient–physician dialogue—such as shorter visits, physician shortages, or weaker primary care infrastructure in rural areas—could in theory translate into measurable disparities.

To investigate, the team turned to the National Health Interview Survey, a nationally representative household survey conducted by the National Center for Health Statistics at the Centers for Disease Control and Prevention. They pooled three cycles of the survey—2019, 2021, and 2023—focusing on men aged 55 and older. Men with a personal history of prostate cancer were excluded, since screening behavior is obviously different for those who have already been diagnosed, as were respondents with missing data on the key variables. The final analytic sample included 15,393 eligible respondents, a large enough pool to support statistically meaningful national estimates once the survey’s complex sampling design was accounted for. After applying the appropriate sampling weights, the researchers estimated that roughly 18 percent of American men in this age group resided in rural areas, a reminder that rural populations constitute a substantial share of the aging male population most affected by prostate cancer screening policy.

The researchers examined three distinct outcomes. The first was whether a man had ever received a PSA test in his lifetime, a measure of cumulative exposure to screening. The second was whether he had received a PSA test within the past 12 months, a closer proxy for current screening behavior in the post-2018 guideline era. The third, assessed only in the 2019 survey cycle, was participation in shared decision-making—that is, whether a clinician had engaged the patient in a discussion of the potential benefits and uncertainties of PSA testing before the test was ordered. This third measure is the most direct window into whether the 2018 guideline’s central mechanism, the informed conversation, is actually reaching patients outside major urban centers.

The headline numbers paint a picture of widespread but incomplete screening engagement. Sixty-one percent of men in the sample reported having received a PSA test at some point in their lives, 39 percent reported testing within the previous year, and among respondents to the 2019 cycle, 48 percent reported having participated in shared decision-making about the test. In other words, even in the post-guideline era, fewer than half of the men facing a screening decision described having had the kind of informed discussion that the US Preventive Services Task Force considers essential. That finding alone is noteworthy, and it holds across both rural and urban populations.

When the team fitted multivariable regression models that adjusted for the survey’s complex design and weighting, the expected rural–urban divide simply failed to materialize. For ever having received a PSA test, the adjusted odds ratio comparing rural and urban men was 0.96, with a 95 percent confidence interval of 0.85 to 1.09 and a p-value of 0.552—statistically indistinguishable from no difference. For testing within the past 12 months, the adjusted odds ratio was likewise 0.96 (95 percent confidence interval 0.85 to 1.07, p = 0.454). And for participation in shared decision-making, the adjusted odds ratio was 0.95 (95 percent confidence interval 0.78 to 1.15, p = 0.586). Across all three outcomes, the confidence intervals straddled the null value comfortably, indicating that whatever differences exist between rural and urban men in this dataset, they are small enough to be explained by random sampling variation.

The authors are careful about how these results should be interpreted, and their caution is instructive. One possibility is that the findings reflect a genuine convergence: following the 2018 guideline, screening conversations and PSA testing may have declined or leveled off similarly in both settings, erasing rural–urban gaps that might have existed earlier. Previous research had documented sharp drops in PSA testing after the Task Force’s controversial 2012 grade D recommendation against routine screening, and studies of the 2018 update found ongoing shifts in testing patterns, but few had examined those patterns specifically through a rural–urban lens at the national level. International evidence from New Zealand and Australia had suggested that remoteness of residence does influence PSA testing patterns, and American studies in regions such as Appalachia had documented more aggressive prostate cancer presentations in rural populations, making the absence of a disparity in screening behavior genuinely unexpected.

A second interpretation, which the authors highlight, involves the COVID-19 pandemic. Two of the three survey cycles included in the analysis—2021 and 2023—captured periods during and after unprecedented disruptions to routine medical care. National data from mid-2020 showed that large fractions of American adults delayed or avoided medical care because of pandemic-related concerns, and subsequent research documented declines in multiple preventive screenings, with some evidence that the disruptions disproportionately affected already disadvantaged groups. If preventive care utilization broadly collapsed during the pandemic years, the rural–urban contrast in PSA testing could have been compressed by a common denominator of reduced access, rather than by equitable improvement. The authors note that their findings might reflect declining preventive care utilization during the COVID-19 pandemic, or similarly low levels of testing and shared decision-making in both populations—two very different explanations with very different implications for policy.

The deeper concern raised by the study may therefore be less about geography than about the low absolute levels of shared decision-making itself. If only about half of eligible men report discussing PSA testing with a clinician before being tested, and that proportion is similar in cities and in the countryside, then the 2018 guideline’s ambition of individualized, informed screening choices is falling short everywhere. Prior studies have found that shared decision-making for PSA testing remains underutilized nationally and that its occurrence varies with patient, physician, and practice-level factors. Prostate cancer screening carries a well-documented tension: PSA testing has contributed to declines in prostate cancer mortality, yet it also generates false positives and detects slow-growing tumors that might never have caused harm, exposing men to biopsies and treatments with lasting side effects. Navigating that trade-off is precisely what shared decision-making is designed to accomplish, and its uneven uptake is a quality-of-care problem that transcends the rural–urban divide.

For clinicians and health systems, the study’s message is twofold. First, rural men in the post-2018 era do not appear to be systematically excluded from PSA screening or screening discussions relative to urban men, at least in self-reported national survey data—a finding that should temper assumptions of inevitable rural disadvantage in this specific domain. Second, and more soberingly, the quality of the screening decision itself appears suboptimal nationwide, with substantial room to improve whether patients live in Greenville, North Carolina, or Manhattan. Because the analysis relied on self-reported survey data, recall and reporting biases cannot be excluded, and the cross-sectional design cannot establish causality or track individual trajectories over time. Still, with a nationally representative sample spanning three survey cycles and rigorous adjustment for the sampling design, the study offers one of the clearest post-guideline snapshots to date of who is getting tested and who is being brought into the conversation. As health systems work to restore preventive care in the pandemic’s aftermath, the findings suggest that efforts to promote genuinely informed prostate cancer screening decisions should target all communities—not only those historically assumed to be left behind.

Subject of Research: Rural–urban disparities in prostate-specific antigen testing and shared decision-making among US men following the 2018 USPSTF prostate cancer screening guidelines

Article Title: Rural–urban disparities in prostate-specific antigen testing and shared decision-making in the US

Article References: Bates, N., Blute, M., Jr., Tumin, D., & Barnwell, P., Jr. (2026). Rural–urban disparities in prostate-specific antigen testing and shared decision-making in the US. Cancer Causes & Control, 37(9), Article 155. https://doi.org/10.1007/s10552-026-02243-z

Image Credits: AI Generated

DOI: 10.1007/s10552-026-02243-z

Keywords: prostate cancer, PSA testing, shared decision-making, rural health, health disparities, cancer screening, USPSTF guidelines, National Health Interview Survey, preventive care, COVID-19 pandemic, overdiagnosis, urology