A central tenet of prostate cancer (PCa) screening guidelines is “shared decision-making” (SDM), in which providers review the risks and benefits of screening with men and help them make decisions appropriate to their baseline risk and subjective preferences. Lack of recommendations for population-based screening has resulted from evidence showing a complex tradeoff in PCa screening efforts, with reductions in mortality and metastasis but an increased risk of over-diagnosis and over-treatment, due to lack of specificity of prostate-specific antigen (PSA) and the indolent behavior of many screen-detected cancers [1], [2], [3], [4]. SDM is considered to be “best practice” in the primary care setting to deal with these ambiguities in a patient-centered fashion. In contrast, guidelines for colorectal cancer (CRC) screening are more compelling, with clear recommendations for screening rather than SDM, due to a well-established mortality benefit and more accurate screening tools. For example, the United States Preventative Services Task Force (USPSTF) recommends screening colonoscopy for those aged 50–75 years at average risk, while only recommending SDM for PCa screening in a similar demographic [5], [6]. The USPSTF recommendations for PCa screening include men ages 55–69, while the American Cancer Society (ACS) recommends SDM for a slightly broader age range, 50–75 years old, which parallels the demographic for CRC screening [6], [7], [8].

Despite stronger evidence for CRC screening, this practice has historically been less common than PSA screening [9]. Less common CRC screening has been attributed to reluctance to undergo an invasive procedure like colonoscopy, stronger media messages for PSA screening, and greater prevalence of PCa leading to more widespread anxiety about this condition [9]. Physician behavior in recommending screening, or engaging patients in discussions around screening, is likely driven by different factors as well, including professional guidelines, medical cultures around screening, and the influence of patient opinion. Notably, all of these variables have changed over time. There has been a significant increase in CRC over the last 20 years while there has been a more recent decrease PSA screening due to changes in guidelines that briefly discouraged screening [10], [11], [12].

SDM is the standard of care for PCa screening and reflects provider attention to an area of medical uncertainty. It represents clinical effort in navigating a challenging subject in a busy primary care setting. SDM ensures that patients understand their options, along with their pros and cons, and that their goals and preferences guide their decisions. In this study, we hypothesized that SDM for PCa screening, given its importance and obstacles, may be a marker of quality preventative care more generally. Specifically, we hypothesized that SDM may be associated with improved rates of CRC screening, which is uniformly recommended for a similar demographic, and possibly other well-established preventative health practices. We sought to answer these questions using data from the most recent Behavioral Risk Factor Surveillance Survey (BRFSS) dataset. The BRFSS is an annual telephone based survey system administered by the Centers for Disease Control and Prevention (CDC) in the United States that gathers data on health behaviors, including the use of preventive services, such as PCa screening and CRC [13]. Since its’ inception, BRFSS has grown to over 400,000 respondents each year, a large representative sample of the nation’s population. Numerous studies demonstrate that BRFSS can be used to identify associations between lifestyle, health behaviors, and medical history [14], [15], [16].