Screening examination for prostate cancer : men ' s experience

To understand the experience of men in achieving screening tests for prostate cancer. We used the reference of Grounded Theory and Symbolic Interaction, respectively, methodological and theoretical with 21 men in São Paulo SP. From the central phenomenon "overcoming the challenge of carrying out the screening tests for prostate cancer", the following categories emerged: experiencing the embarrassment, leading the fear and recognizing the importance of screening tests for cancer. The analysis indicated that the experience of men in clinical exams and knowledge acquired encouraged us to seek prevention. The influence of the social imaginary of the cancer disease and the stigma of tracking can accommodate, inhibit or fill with fear and shame the man who submits to the examinations. Thus, the first step to define strategies for more effective interventions is to understand how a population perceives, feels and lives the health.


INTRODUCTION
Prostate cancer is the fifth most malignant tumor in the world.Brazil is among the countries with high incidence rate and the estimate for 2014, according to the National Cancer Institute (INCA), is 68,800 new cases with 35,980 of them in the Southeast region 1 .The incidence of this disease increases over the years.Several risk factors are determinants, such as: the higher life expectancy of the population, the constant campaigns to identify the disease revealing more men with the disease, dietary and environmental influences 2 .
It is important to consider that the incidence and mortality increases significantly after 50 years old.Family history, i.e., father or brother with prostate cancer before 60 years old may increase the risk of having the disease three to ten times compared to the general population 2 .
Despite the differences in the literature about the need for routine screening for prostate cancer reducing mortality from this injury, its practice is generalized 1 .Early detection is very important to increase the chances of cure.The Brazilian Society of Urology recommends until new evidences, the trace of malignant prostate cancer by annual prostate specific antigen known as PSA and rectal examination in men between 50 and 80 years olf.In men with first-degree relatives diagnosed with prostate cancer screening may begin at 45 years old 3 .
Rectal examination is relatively a low cost preventive measure 4 .However, this procedure affects the male imagination, making men going away from prevention of prostate cancer.The refusal of rectal examination does not necessarily occur only by the lack of information about the effectiveness of this preventive measure.It is about the symbolic aspects concatenated to its invasive nature, physically and emotionally, and the spread of fear of the examination among men; as well as structural aspects associated, such as access to screening in health services and the recommendation or not of the health professionals 5 .
Besides these factors, the presence of symptoms such as pain or discomfort can motivate or encourage certain health practices.Health education is an important external factor to stimulate the realization of preventive screening for prostate cancer 6,7 .
For preventive actions become part of the health care of males, there is a need to bring health services to the demands of men, adding in the professional's practices the guidelines issued by the public health policies, programs specifically meeting the man in full, not focusing on the cause of the disease that led him to the consultation, but the actions implemented in order to receive the man in a extended clinic.
For being one of the significant causes of morbidity and mortality, prostate cancer is a multifaceted and emerging issue that requires health professionals, especially nurses, expressive indication of dedication to prevention, assistance to the person collaborating with the planning and evaluation of assistance to man in order to achieve the promotion and maintenance of health 7 .
With this topic complexity and the subjectivity involving the perceptions of men in the object under study, the question is: how does the man experience the fulfillment of screening tests for prostate cancer?
This study aims to understand the experience of men in achieving screening tests for prostate cancer.

METHOD
This is an exploratory, descriptive and qualitative study, using the references of Grounded Theory (GT) and the symbolic interaction, methodological and theoretical respectively.
The symbolic interaction emphasizes the meanings as determining factors in human behavior, considering these values constantly revisited and transformed from the interactive process with the individual elements of the own universe 8 .
Using the symbolic interaction in this study was to know each significant element for the individual who experiences the examinations for screening prostate cancer.
The Grounded Theory (GT) seeks to understand the reality from the perception or meaning that a certain context or object has to the person generating knowledge, increasing understanding and providing a significant contribution to the actiob 9 .This methodological approach allows the development, inductively, of knowledge from the experience lived by the men participating in this study.
Initially, participants selection was with the help of key informants, i.e., health professionals who had knowledge about the population study 10 .In this case, there were three physicians performing screening tests for prostate cancer and routinely work in health institutions in São Paulo -SP.
The continuity of the selection was by using the technique in snowballs 10 , i.e., from the identification and location of an initial group of respondents with certain characteristics adopted as inclusion criteria.These respondents also constitute informants to identify other participants with the same characteristics to be included in the investigation, and the process successively repeated to identify the greatest number of individuals who can contribute to the study process 10 .
First, we did an informal contact to check the availability of the person for the research.Subsequently, we arranged each interview in the person's residence, date and time chosen by each subject.The first ten respondents were people who lived in different areas of the city, not establishing between themselves any bond of friendship or kinship.
As inclusion criteria were the following characteristics: men living in São Paulo -SP, aged ≥ 50 years old, without cognitive impairment, no history of prostate cancer who have undergone Screening examination for prostate cancer Belinelo RGS, Almeida SM, Oliveira PP, Onofre PSC, Viegas SMF, Rodrigues AB at least one screening tests for prostate cancer (combination of two or more tests: PSA and rectal examination or PSA, rectal examination, transrectal and pelvic ultrasonography).
Data collection was between July and September 2012, through interviews in two parts.The first, to characterize the study's participants (age, self-reported skin color, marital status, education, income, current work, family history of prostate cancer, reasons for carrying out preventive examinations).The second, consisting of open questions about how is the experience of men in the screening tests for prostate cancer.We scheduled the interview previously by phone, held at the participants' homes and recorded after authorization, with an average duration of 35 minutes.There was a formal presentation of the research in the residence for ethical criteria.
Theoretical saturation occurred at 21 st interview, related to the analysis of the data so the emerged categories develop and densify more.To ensure anonymity and confidentiality of participants' information, we used pseudonyms formed by the letter P of participant and then the sequence corresponding to the number of interviews.
The analysis started by open coding of the data, with precise detailing of content of the speech, to elaborate the units of analysis.In axial coding, there were categories and subcategories along the lines of their properties and dimensions.In selective coding, we generated the paradigmatic model that establishes a relationship between categories, involving, respectively, cause, phenomenon, context, intervening conditions, strategies of action/interaction and consequences 9 .
The research meets the regulatory guidelines for research involving humans according to CNS Resolution 196/96 imposing periodic revisions to it as needs in techno-scientific and ethics areas, made by CNS Resolution 466, of December 12, 2012.The Ethics Committee of Paulista University and Research (COEP) by CAAE Nº 0001.0.251.000/11under Protocol Nº 015/11 approved the study.We asked the participants about their voluntary participation, and after accepting, they signed the consent form.

RESULTS AND DISCUSSION
Of the 21 men aged 51-77 years old, the average age was 60.2 years old.Regarding to education, eight men completed more than 12 years, four respondents attended school for 10 to 12 years, six attended five to nine years of study and three attended school for less than five years.Regarding income, eight respondents reported incomes greater than seven minimum wages, six reported receiving between three and six minimum wages and eight received between one and two minimum wages.
In relation to work, ten men reported being unemployed, six were autonomous and five reported being retired.Among the practiced activities, there were lawyer, administrator, engineer, salesperson, mechanic, plus driver and porter.Regarding ethnicity, 12 reported they were white, seven black and two brown.
Of the total of the participants, fifteen said they had no family history of prostate cancer; three cited the father and three reported having a brother with prostate cancer.
The reasons given by participants for the realization of preventive screening for prostate cancer were: preventive measures, advanced age, signs and genitourinary symptoms, fear of disease, pressure from his wife and experiences of family and/or friend who died of the disease.Regarding marital status, nineteen were married, one divorced and one widowed.
Studies have shown a lower prevalence of achievement of screening tests for cancer in men without spouses, whose finding is attributed to the fact that they have companions to encourage health care 11,12 .
As for testing to detect prostate cancer, 15 participants did rectal examination associated to measurement of PSA and six did pelvic ultrasound and transrectal in association with two other tests mentioned above.
The findings of the rectal examination associated with the result of measurement of PSA can indicate the presence of disease.On the rectal examination trying to assess the prostate, its size, if there is consistency and presence of nodules.The PSA is a serine protease whose function is to cleave and liquefy the seminal coagulum formed after ejaculation.In men without prostate disease, only tiny amounts circulate in the blood 7 .
The results of rectal exams and PSA dosage contribute to the diagnosis of prostatic diseases.However, when one is not sure of the absence of the disease, may be necessary to perform pelvic or transrectal ultrasonography.The result of the ultrasonography indicates the need for transrectal prostate biopsy.The diagnosis is confirmed by the study of pathological prostate tissue obtained by biopsy, but any of the participants of this study had to undergo biopsy 2 .
The use of the GT method to understand the experience of men in achieving screening tests for prostate cancer, originated the central phenomenon: overcoming the challenge of carrying out the screening tests for prostate cancer.From this, the following categories emerged: experiencing the embarrassment; living with fear; and recognizing the importance of screening tests for prostate cancer.
There is a framework to build an explanatory paradigm that includes the following aspects of the phenomenon developed by TFD 9 scholars: causal conditions; intervening conditions, context, action and interaction strategies and consequences.In Figure 1, there is the diagram of the analysis developed by the authors, in the symbolic interaction, referring to the causes of the phenomenon, i.e., the set of events, incidents and events that lead to the occurrence or development of the phenomenon and interpretation.

Category: experiencing the embarrassment
Statements of the participants of the study revealed that the feeling of embarrassment was because of the type of examination; in this case, the rectal examination, of the sexual connotation that acquires and triggers prevention of prostate cancer related to male sexuality by the threat to masculinity bias.
Men can show resistance and embarrassment to the rectal examination because it dishonors his manhood, in his condition of being an active male 5 .This resistance emerges, however, because rectal examination is something against the conception of male.In such cases, masculinity is the framework for identity formation, dictating concepts to be recognized as "real men" and not being questioned by those who hold the same beliefs.

Screening examination for prostate cancer
Belinelo RGS, Almeida SM, Oliveira PP, Onofre PSC, Viegas SMF, Rodrigues AB Therefore, being a man is a relentless exercise in denial rather than affirmation, denying female characteristics to optimize and approaching what is believed to be the ideal image of man culturally constructed throughout life 13 .Some examples show expressions of men who reflect the experience of embarrassment to perform rectal examination and the evidence that this examination affects the male is: I felt very embarrassed because it has that touch with the finger, which I did not know how was it (P12).
Slightly embarrassed, it involves the male imaginary, but after you do it the first time, you can see that it is a test, but it is a bit difficult to do it, you do more because of the need and the prevention (P6).

Actually I felt embarrassed, ashamed, it is an invasion, I am a man (P21).
The examination of touch, which is the most annoying, I felt half embarrassed, it was a little sore, but far less than I thought (P4).
It is evident that the rectal examination can be embarrassing, emerging as a breach in the reports, and this can be seen as a symbolic space to disrupt the identity being a men 13,14 .These symbolic perspectives of masculinity, if they do not worked them, can derail the measure of screening for prostate cancer, but also leave the care to men's health 15 .
Knowledge and understanding of the history of male sexuality can help to find the answers to many current questions involving practices and fears in men, especially when they are related to their body.Thus, it is important to consider the cultural dimension of the body considering that practice and learn on the body are not exempt from historicity.In this perspective, a man has always been associated with invulnerability, strength and virility, characteristics incompatible with the demonstration of embarrassment, weakness and insecurity 13 .When entering in the body in places considered forbidden for heterosexual men, the least that can happen is an embarrassment.
The simple act of touching the gluteal area, a forbidden part of the male body is invaded; rectal examination can symbolically be linked to sexual penetration 5 .The statements below are examples:

Look, I was in that position that Napoleon lost the war, you know how? [...] get down on all fours on an examination table is embarrassed, my rectum was impenetrable [...]
the doctor was still talking all the time, about my prostate.I should be beautiful inside, because his enthusiasm was really contagious, as the exam finished as we finalized a sexual, I'm sure I was red and then left as quickly as I could in that room.But

now I lost my anal virginity [laughs] I do it every year, it is always annoying, but never like the first time, the important thing is to be healthy (P16).
Other studies corroborate this association of rectal touch of masculinity and humiliation to the point that men consider the worst thing that happened to them and should have another way of examining.They only do the exam because they are aware of the need 5,15 .
It is noteworthy that the rectal examination can trigger the feeling of reversing male.Being passive is associated with being penetrated.Metaphorically, men dominate and penetrate women and homosexuals.The act of being penetrated is contrary to the male culture because being male is being active and never passive 5,14 .
In an interaction perspective, humans are social actors, which take into account the other when they act.We communicate symbolically in our actions and interpret the actions of each others 8 .The interaction occurs in a continuous flow of actions among actors, becoming the basis for what we decided to do in the situations.
In symbolic interaction, the meaning of things is in the rationality of human action and, more precisely, the source of meaning, i.e., emerging in the interaction process; so these men, having experienced the rectal examination, impact before the feeling of violation of his manhood.
Based on this discussion, the rectal examination is not only a physical penetration, but also it can be symbolically associated with the violation of the male.This scenario of stigma leads to high prevalence of diagnosis of prostate cancer in advanced stage and unfortunately poorer prognosis.

Category: living with fear
Fear of the disease, of pain and death leads men to care for the body.This fear takes him to the clinic seeking prevention of prostate cancer, but at the same time, they feel fear about the result of the examination.This ambiguity of feelings may also relate to the historical construction of the cancer.Historically, cancer was a declaration of death; cancer was shame, divine punishment, from the zone of silence to speak in the disease, the patient's responsibility; cancer is a disease surrounded by stigmas 6 : Screening examination for prostate cancer Belinelo RGS, Almeida SM, Oliveira PP, Onofre PSC, Viegas SMF, Rodrigues AB

Look, actually I felt fear, very afraid of having a positive result, my brother has this disease in the prostate, I was worried I would also have with the disease, my brother has metastasized, suffering (P5).
I was scared because the doctor had forced me to take the exams, I got scared and thought that I will get cancer.

Do I have cancer, what will happen to me if I have this disease? (P7).
Fear, I felt very afraid, afraid of hurting and even out the test results, look, every year is the same thing, I'm afraid even to the result (P9).
I was afraid of the examination and be until the exam's result we get worried, scared living with cancer, in it the last time I was with difficulty to urinate, but thank God, it was hyperplasia, I'm taking medicine but is a relief not to be cancer (P11).
In prevention for prostate cancer, there are studies that show that fear is one of the main explanations for the low demand for primary health 6,16 , similar result to this research.This fear is of discovering that something is not right, and that feeling is common in individuals, regardless of sex.People fear that in seeking health services to see if their health goes well, they can find the diagnoses of a disease and having to deal with 15 .
This distressing expectation is because the idea of a man not being able to elaborate what will be informed, that is, not being able to make the necessary changes in the symbolic structure that new meanings with the news of the disease may require, damaging the life of a being who was healthy until performing the screening.
In the rectal examination, besides the sadness of having to go through it and the result, there is a fear of pain, as a justification for not seeking the examination or do it, but with fear.However, invasion of privacy, psychological distress and physical factors to conceal the subjectivity of the problem, reduced, only the physical aspect of pain 16 .
However, as already discussed, the rectal examination, more than in the prostate, it touches on masculinity, the embarrassing position by the invasion of privacy, the feelings of helplessness and shame in a society considered patriarchal and sexist.
Sexism of skills produce an unsystematic but compelling training in what would be desirable for a man: since small, they have an education about how to defend the sisters, face dangers, winning in games, in sports.As adults, they should be the best in their professional activities, always be manly, conquering several women, be providers, among other skills; the ideal of masculinity that will solidifying the innermost core of the identity of the man 7,5 .These values created the masculine subjectivity and, moreover, the men do not feed care, the fear; then confusing personal identity and gender identity.
Each individual has a historical, cultural and social integration and, in that sense, stressing the symbolic universe, each person will have his own design actions and attitudes that will be raised by health professionals -or should at least attempt to occur -in the sense of a full and proper understanding of what are the possibilities of health education for men.
The interaction approach argues that in confronting the world of objects that surrounds it, the social actor interprets it in order to act.This phenomenon is the experience of men in carrying out the screening tests for prostate cancer by deciphering a series of symbols that involve experienced situation, which can give meaning to these scans to enlarge the prevention of men's health.
The results raise the need to intervene, through health education, to autonomous choices regarding the practice of health promotion and disease prevention.It is also essential to identify strategies over the medium and long terms that allow the modification of beliefs in the collective unconscious of men about screening tests and on prostate cancer.
In this context, there is the indication of the organization and planning of scheduled health actions, considering the individuality and dignity, creating a bond, the co-responsibility and professional performance precise and resolute 6,16 , recognizing that men, to submit to examinations screening for prostate cancer, carry and maintain their beliefs and values.

Category: recognizing the importance of screening tests for prostate cancer
To overcome the barrier of the first rectal examination, men express in their reports, the maturity and the recognition of preventive measures for health care: I overcame barriers because I know of the need to take care of myself, my tests are normal, it is important to check up every year, I'm old, knowing that early there is treatment, the possibility of cure is greater, I want to live a lot (P14).
Look, I know that exams are important and necessary, the rectal examination is a serious act and completely professional, care for me is the truest way for me to show my wife how much I love her, we've been together for 30 years and I be healthy to stay 30 more years with her, I'm very happy, she's beautiful, intelligent, cheerful, we are very happy (P19).
The first rectal exam is tough, but after that everything went normal I think about my health, the importance of Screening examination for prostate cancer Belinelo RGS, Almeida SM, Oliveira PP, Onofre PSC, Viegas SMF, Rodrigues AB taking care of myself, to prevent cancer, then I do every year, my father died of this disease in the prostate (P17).

My exams are ok every year, taking exams, health care, go to the doctor every year is important for all people after 40 years old. I believe and put into practice what I believe (P13).
The only thing of preventive tests that we cannot stop talking about is that the rectal exam is painful... but it is necessary (P8).
Men are reasons for the choice of tests done.The motivation for screening is a kind of social accumulation of knowledge transmitted by predecessors such as cultural heritage and the knowledge gained from experience 16 .Also by way of argument to remaining healthy in an emotional and sexual relationship, that brings happiness.
Considering the impact of prostate cancer on the experience of sexuality and the construction of masculinity for affected men, the confrontation of the man screening determines a reconfiguration of notions of sexuality 17 .The relief is "for not having the disease "after the test results indicating the normality and the reason for the continuation of the examinations periodically.
Over the years, we learn to live with the pleasant and the unpleasant, through maturity, allowing the overcoming of naive position that can allow us to select only the positive aspects of our daily lives to our life experiences.Finally, we develop the ability to reflect on reality, seeking forms of assistance to enable the maintenance of the vital realization of each individual 5,11 .
In this study, the experience of men for screening for prostate cancer is full of excuses of why and how to arrive at this choice, but also expressed by the participants in the lack of psychological structure to receive a diagnosis of prostate cancer, giving them the anguish and uncertainty, changing their attitudes or even inhibiting the choice for prevention.
Nurses should not miss the opportunity to approach men, enjoying the everyday situations of nursing care from the perspective of health promotion and early detection of diseases, to educate them about the risk factors and preventive measures for prostate cancer and to identify the presence or absence of these factors and seek signs and symptoms that may indicate changes related.
The areas of health should be for promoting the production of quality of life, including in situations of hospital care, which is relevant to the extent that men seek services, most often, for emergency and not deliberate and programmed for health maintenance 18:387 .
From the perspective of a symbolic interaction, existing worlds for people are physical, social and abstract objects, and the objects may take different meanings for different individuals 8 .That is because social interaction is a process that guides human behavior and is valid for those involved in the preventive process of prostate cancer such as health professionals and men who are experiencing the preventive measures of diseases and promotion of health.

FINAL CONSIDERATIONS
Conducting this study with the symbolic interaction and the methodological steps of Grounded Theory allowed unveiling the experience of men on performing screening tests for prostate cancer, identifying their meanings and feelings.
The influence of the social imaginary of the cancer disease and the stigma of screening for prostate cancer can accommodate inhibit or fill with fear and shame the man who submits to the examinations.Thus, we need to understand how a given population or a specific risk group perceive, feel, and experience health because it is the first step to define strategies for more efficient and suited to the real needs of people and community interventions.
Educational activities in health may contribute to the transformation of preventive care practice and better perception of men about their relevance in health care.
From the respect to uniqueness and human dignity, professionals may decrease the embarrassing and fears of men so that they are more autonomous and participating in the production of their health.
It is worth mentioning the study's boundaries, although covering the experiences of men in carrying out the screening tests for prostate cancer this is not an absolute reality for all who are experiencing these examinations.The unpredictability of the results of screening tests for prostate cancer and other charges can bring conflicts considered and evaluated by health professionals to assist these men in directing actions to be implemented.

Figure 1 .
Figure 1.Diagram describing the causal conditions, context, intervening conditions, strategies of action/interaction, central phenomenon and consequences from the experience of men on performing screening tests for prostate cancer.