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AUTHOR REPLY

      We want to thank Urology and the Editorial Response authors for 1 considering the importance of how the social determinants of health (SDH) affect shared decision making (SDM) for prostate cancer screening. Health literacy (HL) plays a particularly important role in prostate cancer screening, when considering the best interest of the patient and mitigating over-utilization of health care resources. It is well documented that racial barriers influence access to health care screening; surprisingly, our study illustrates that African-American men had higher rates of PSA testing. This was an interesting finding given African-American men are more likely to report lower levels of health literacy. This discrepancy may be due to the practice of SDM. With ambiguous guideline recommendations on PSA testing, prostate cancer screening remains a more complicated space, requiring the fine balance of patient beneficence, non-maleficence, justice and autonomy. When counseling patients and considering their preferences it is important to consider how HL, race and other SDH factor into the SDM process. Moving forward we recommend continued investment in community programs which promote HL, in addition to population-based study of how SDH influence the SDM model of prostate cancer screening.
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