# Multilevel associations between prostate cancer testing and socioeconomic position: a population-based register study from Stockholm, Sweden

## TL;DR

This study shows that prostate cancer testing rates are linked to both personal and area-level income and education, with higher testing in wealthier areas.

## Contribution

The study quantifies how socioeconomic factors at multiple levels explain spatial variation in prostate cancer testing.

## Key findings

- Men with higher education had 22% higher odds of PSA testing compared to those with less than 9 years of education.
- Income explained 42% of the spatial variation in PSA testing at the area level.
- The highest PSA testing rates were observed in men aged 70–79 with the highest income.

## Abstract

Prostate cancer testing is associated with both individual and area-level socioeconomic position (SEP), but the multilevel nature of this association is unclear and contribution of SEP to the spatial variation is unknown. This study investigated the association of widespread opportunistic prostate-specific antigen (PSA) testing with SEP measures and quantified the extent to which multilevel measures of SEP contributed to the observed spatial variation in PSA testing.

A population-based register study was conducted, encompassing 471 335 men aged 40 years and older without a prior prostate cancer diagnosis residing in the Stockholm region in 2016. We used hierarchical Bayesian logistic regression models with spatial random effects to estimate the associations between PSA testing and SEP measures.

Men aged 70–79 in the highest income quartile had the highest proportion (35.2%, 95% CI 34.5% to 35.9%) of PSA testing in 2016. Adjusting for age and spatial variation, men with at least 12 years of education for having a PSA test had a 22% (95% CI 19% to 25%) higher odds compared with men with less than 9 years of education. For small area level variance in PSA testing, the highest proportion (42.0%) explained was seen for income.

The findings suggest a moderate association between opportunistic prostate cancer testing and SEP measures at the individual and area levels. The SEP measures at the individual and area levels substantially explained the spatial variation in PSA testing, where income was the strongest driver. Future strategies for prostate cancer testing should be aware of SEP differentials at both individual and area level to reduce socioeconomic inequities in incidence and mortality.