Composition Vendor Newgen KnowledgeWorks (P) Ltd. PLoS One plos plosone PLOS One 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0349758 PONE-D-26-08019 Research Article Medicine and health sciencesUrology Medicine and health sciencesOncologyCancers and neoplasmsGenitourinary tract tumorsProstate cancer Medicine and health sciencesUrologyProstate diseasesProstate cancer Medicine and health sciencesHealth careHealth care policyScreening guidelines Biology and life sciencesPsychologyPsychometrics Social sciencesPsychologyPsychometrics Medicine and health sciencesHealth careHealth care providersPhysiciansGeneral practitioners People and placesPopulation groupingsProfessionsMedical personnelPhysiciansGeneral practitioners Medicine and health sciencesDiagnostic medicineCancer detection and diagnosisCancer screening Medicine and health sciencesOncologyCancer detection and diagnosisCancer screening Research and analysis methodsResearch designSurvey researchQuestionnaires People and placesGeographical locationsEurope Disparities in prostate cancer screening practices among general practitioners and urologists (PROSHADE study): A cross-sectional study Disparities in prostate cancer screening practices (PROSHADE study) https://orcid.org/0000-0003-1665-0860 Lumbreras Blanca Conceptualization Methodology Writing – original draft 1 2 * Parker Lucy A. Conceptualization Formal analysis Methodology Writing – original draft 1 2 Alonso-Coello Pablo Conceptualization Formal analysis Writing – original draft 2 3 Caballero-Romeu Juan-Pablo Conceptualization Formal analysis Methodology Writing – original draft 4 5 Párraga-Martínez Ignacio Conceptualization Writing – review & editing 6 7 Prieto Luis Conceptualization Writing – review & editing 4 Moral-Peláez Irene Conceptualization Writing – review & editing 8 del Campo-Giménez Mª Conceptualization Writing – review & editing 9 Gómez-Pérez Luis Conceptualization Writing – review & editing 10 Cebrián Ana Conceptualization Writing – review & editing 11 López-Garrigós Maite Conceptualization Writing – review & editing 2 12 https://orcid.org/0000-0003-1886-466X Ronda Elena Conceptualization Writing – review & editing 2 13 Guilabert Mercedes Conceptualization Writing – review & editing 14 Canelo-Aybar Carlos Conceptualization Writing – review & editing 2 3 Hernández-Aguado Ildefonso Conceptualization Writing – review & editing 1 2 Department of Public Health, History of Science and Gynecology, Miguel Hernandez University, San Juan de Alicante, Spain CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Re-search Institute Sant Pau, Barcelona, Spain Department of Urology, Dr. Balmis General University Hospital, Alicante, Spain Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain Medical Sciences Department, Medicine Faculty, University of Castilla-La Mancha, Albacete, Spain Primary Care Research Group, Health Research Institute of Castilla-La Mancha (IDISCAM); Health Care Center Zone VIII, Servicio de Salud Castilla-La Mancha, Albacete, Spain EAP Sardenya, Barcelona, Institut de Recerca Sant Pau, Barcelona, Spain Integrated Care Management of Albacete, Health Service of Castilla-La Mancha, Barcelona, Spain Department of Urology, University General Hospital of Elche, Elche, Spain Cartagena Casco Healthcare Centre, Cartagena, Spain Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Spain Public Health Research Group, Alicante University, San Vicente del Raspeig, Spain Department of Health Psychology, Miguel Hernandez University, Elche, Spain Lawal Ismaheel Editor Emory University, UNITED STATES OF AMERICA

No financial disclosures were reported by the authors of this paper.

 * E-mail: blumbreras@umh.es 2152026 2026 21 5 e0349758 2122026 452026 2026 Lumbreras et al This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction

Recent European recommendations promote risk-based, patient-centred screening models that emphasise shared decision-making (SDM) in prostate cancer (PCa) screening with prostate-specific antigen (PSA) testing. Understanding how clinicians apply these practices is essential, particularly given the roles of general practitioners (GPs) and urologists in detection. The aim of this study was to compare the knowledge, attitudes, and practices of GPs and urologists in Spain regarding PSA testing, PCa screening, and SDM implementation.

 Methods

Cross-sectional survey conducted via an online questionnaire. Members of the Spanish Association of Urology (AEU) and the Spanish Society of Family and Community Medicine (semFYC) were surveyed online. The survey, developed and validated using a modified Delphi process, contained 18 items assessing clinicians’ opinions, practices, and knowledge of guidelines. Data from 494 respondents (280 GPs and 214 urologists) were analysed using descriptive statistics and logistic regression to explore differences between specialty, demographics, and screening practices.

 Results

Urologists were more likely than GPs to consider PSA testing important (97.2% vs. 83.2%) and useful (96% vs. 44.4%), and to recommend it to relatives (90.4% vs. 44%) (all p < 0.001). They reported to initiate testing earlier (50–59 years: 77.8% vs. 32%) and reported to perform it more frequently (annual testing: 60.7% vs. 45.6%, p < 0.001). GPs reported to more often engaged in SDM when ordering PSA tests (69.7% vs. 10%, p < 0.001). Knowledge of guidelines was higher among urologists (91% vs. 24.1%), yet 75.4% stated that they had not modified practice following updated recommendations.

 Conclusions

Significant specialty-based differences exist in PSA testing practices, perceptions, and guideline adherence. Urologists show greater familiarity with recommendations, while GPs reported more patient-centred communication.

 http://dx.doi.org/10.13039/501100004587 Instituto de Salud Carlos III PI20/01334 https://orcid.org/0000-0003-1665-0860 LumbrerasBlanca Research was funded by the Instituto de Salud Carlos III, code PI20/01334, co-financed with FEDER funds from the European Union “A way of doing Europe”. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data Availability The dataset generated and analyzed during the current study is available in Zenodo at https://doi.org/10.5281/zenodo.19983225. Introduction

Cancer remains one of the leading causes of mortality in Europe, and poses major health, social, and economic challenges. The European Commission launched Europe’s Beating Cancer Plan (EBCP) in 2021, an ambitious, patient-centred strategy aimed at reducing the cancer burden through coordinated actions in prevention, early detection, diagnosis and treatment [1]. One of the priorities of this plan is to promote cancer screening through risk-based and personalised approaches.

Prostate cancer (PCa), the most frequently diagnosed malignancy among men in Europe, is one of the main targets of this strategy. Although the prostate-specific antigen (PSA) test has contributed to earlier diagnosis, its limited specificity has also led to substantial overdiagnosis and overtreatment [2]. To address these challenges, the European Association of Urology (EAU) has proposed a multi-risk algorithm that integrates PSA testing within a broader risk-adapted model for early detection. This approach combines PSA results with individual factors such as age, family history, ethnicity, genetic predisposition, and, when appropriate, complementary assessments including multiparametric magnetic resonance imaging (MRI) and molecular biomarkers [3]. Recent policy developments, such as the EUCanScreen programme [4], reflect a coordinated effort to improve the quality, accessibility, and effectiveness of cancer screening programmes across Member States. In parallel, the Council Recommendation of 9 December 2022 [5] on strengthening prevention through early detection provides updated guidance that addresses the need to expand and refine screening strategies beyond certain specific cancers. This recommendation identifies PCa screening as a key area for further development, acknowledging both the preliminary evidence and the widespread use of opportunistic screening practices across Europe. It encourages countries to adopt a gradual and evidence-based approach, through the implementation of pilot programs with the generation of additional research. Furthermore, it underlines the importance of evaluating PSA testing in combination with MRI as a follow-up diagnostic tool, particularly within the context of organised screening programmes, in order to assess feasibility, effectiveness, and potential benefits versus harms.

This represents a sensible and patient-centred strategy that balances the benefits of early detection with the potential harms of overdiagnosis and overtreatment. Thus, the implementation of shared decision-making (SDM) in this strategy is crucial. SDM ensures that men are fully informed about the benefits, limitations, and potential outcomes of PCa screening, which empowers them to participate actively in decision-making. However, its implementation in clinical practice varies widely [6,7].

Both general practitioners (GPs) and urologists play critical roles in implementing this new approach. GPs are typically the first contact point for men considering screening and are responsible for initiating informed discussions [8], while urologists provide specialist evaluation, diagnostic interpretation, and management of abnormal findings [9]. These incidental findings also require an approach that includes clear communication with patients and timely referral to appropriate specialities (e.g., radiology, oncology or other relevant disciplines), to ensure personalised assessment and follow-up which minimize unnecessary interventions and patient anxiety [10].

Effective collaboration and alignment between these two professional groups are essential to ensure consistency, accuracy, and patient trust in clinical recommendations [11]. In addition, urologists have access to a wider range of diagnostic options than GPs, including the use of additional biomarkers and multi-parametric MRI, and are therefore, more likely to integrate these risk-adapted approaches [12]. However, GPs usually base themselves solely on PSA levels, leading to variability in clinical decisions. A study on PSA testing practices found that GPs were less likely to routinely order PSA tests compared to urologists, largely due to concerns regarding false positive results, overdiagnosis, and the resulting potential psychological burden on patients [11]. In addition, although this manuscript focuses primarily on the roles of GPs and urologists, it is important to recognize the broader governance framework needed for effective implementation of organized screening programs. In particular, public health specialists play a central role in ensuring adherence to protocols, population coverage, and the promotion of informed participation [13]. In addition, other clinical specialists such as radiologists and pathologists are essential for accurate imaging interpretation, diagnostic confirmation, and risk stratification in the screening pathway [14]. Moreover, the involvement of professional associations and patient organizations, in order to align patient needs, is essential for the cocreation of screening strategies [15].

In this context, assessing the knowledge, attitudes, and practices of GPs and urologists regarding PSA use, screening, and SDM becomes a necessary step for implementing the EAU and EBCP recommendations in routine clinical practice. Conducting a survey among GPs and urologists can provide valuable information about their familiarity with screening practices, PSA use, and their communication strategies for addressing the benefits and risks of screening. It can also identify differences in understanding, perceived barriers, and training needs that may influence clinical practice. Although several previous surveys have examined clinicians’ knowledge and practices regarding PCa screening [16] it remains necessary to reassess this knowledge in the context of the most recent European recommendations.

Therefore, the present study aims to explore and compare the knowledge, attitudes, and practices of GPs and urologists regarding PSA testing, PCa screening and SDM. By identifying common barriers and differences between both groups, the study seeks to provide evidence to guide educational strategies and facilitate the successful implementation of the European risk-based screening model in clinical practice.

 Materials and methods

The protocol of the PROSHADE study has been previously published [17]. The reporting of the manuscript follows the STROBE [18] recommendation (S1 Table).

Design

Cross-sectional survey based on an online questionnaire.

 Questionnaire

The survey was developed following a systematic review of the literature [16] Based on this, the coordinating group drafted an initial version of the questionnaire, which was refined and validated using a modified Delphi method. A panel of experts—including GPs, epidemiologists, urologists, a lab physician, and a psychologist—reviewed the questionnaire in two rounds of virtual voting, rating item relevance and suggesting improvements. In the final phase, a pilot study was conducted with the expert panel and 10 family doctors and urologists. No major changes were needed after the pilot. The questionnaire validation process included assessing the degree of consensus regarding the relevance of item for inclusion in the final questionnaire. Content validity was analyzed through item averages, Aiken’s V test, and qualitative expert assessments to adjust questionnaire categories. Criteria for item selection were a mean score above 3.5 and Aiken’s V test result greater than or equal to 0.70. Items with a lower 95% confidence interval limit below 0.70 were included if the mean exceeded 3.5 and the median was 4 or higher. We collected the expert’s evaluations using Google Forms and analyzed the data with IBM SPSS Statistics v27 for Windows. The final version of the questionnaire included 18 questions related to opportunistic PCa screening and the PSA testing: 4 questions about clinician’s opinions, 10 questions about routine practice and 4 questions about knowledge and use of current guidelines. Answers were all presented as Likert scale (Supplementary S2).

 Subjects and procedure

Clinicians (urologists and GPs) were selected through collaboration with two major Spanish scientific societies: the Spanish Association of Urology (AEU) and the Spanish Society of Family and Community Medicine (semFYC). These societies were contacted and agreed to support the study by facilitating access to their members. An invitation to participate was distributed to urologists and GPs through internal mailing lists and communication channels managed by each society. The invitation included a brief description of the study objectives, participation requirements, and a link to the online survey. The survey was administered using a Google Forms questionnaire, allowing for distribution, anonymous responses, and centralized data collection. Survey was carried out between: 01/05/2024–31/07/2024. We did not have access to information that could identify individual participants during or after data collection.

 Sample size

The aim of the study was to assess the knowledge, opinions, and implementation of SDM in practice of GPs and urologists regarding PCa and PSA testing in opportunistic PCa screening. We focused on the implementation of SDM in practice as the main outcome for calculating the sample size (since it is the most unfavorable outcome of the three proposed objectives). According to a recent systematic review [16], a minimum of 384 participants would be required to estimate this proportion with a precision of 5% at a 95% confidence level under a simple random sampling assumption. However, as participants were recruited through a convenience sampling approach—consisting of clinicians who voluntarily responded to the survey invitation distributed via scientific societies (there are 1,630 urologists included in the AEU and 20,000 GPs in the semFYC)—this calculation was used only as a reference to ensure an adequate sample size rather than to support formal precision estimates. Recruitment was therefore continued until a sufficient number of responses from both specialties was obtained to allow meaningful comparisons between groups.

 Variables included

The independent variables included in the questionnaire were: sex, age (years), specialty (GPs and urologists), years of practice (including specialty), regular formation received regarding the PSA test (defined as having received prior formal or structured training on PSA testing, including its indications, interpretation, and clinical management, through continuing medical education activities such as courses, workshops, or similar programs), and type of centre where the clinician works (public, private or both).

 Statistical analysis

The data collected in the study was coded and recorded in a specifically designed database. Analysis was performed using IBM SPSS Statistics 27.0 (IBM Corp., Armonk, NY, USA).

We assume that missing values occurred at random (there were no differences between those cases who answered a particular question and those who did not) and thus, we did not omit those cases with missing data and analyze the remaining data). However, to explore this assumption, we compared key characteristics (sex, specialty, and years of practice) between participants with complete data and those with missing responses for the main variables, and no relevant differences were observed. Sensitivity analyses were conducted using complete-case datasets, and the results were consistent with the primary analyses.

The descriptive statistics for categorical variables were expressed in numbers and percentages. The association between the independent variables included in the questionnaire (sex, age, specialty, years of practice) and the clinicians’ opinions about opportunistic PCa screening and the PSA testing were tested using the Chi-square test. This test was also used for the analysis of differences in routine practice in PSA screening for prostate cancer by specialty and also for the analysis of the differences in the use of available guidelines according to the information provided on the advantages and disadvantages of PSA determination and specialty. A p-value <5% was considered statistically significant. Continuous variables were assessed for normality and, as they were not normally distributed, are presented as medians and interquartile ranges; comparisons between groups were performed using the Mann–Whitney U test.

Given the number of Chi-square tests performed, we acknowledge the potential for increased Type I error. These analyses were exploratory and aimed at identifying patterns between specialties rather than testing a single predefined hypothesis; therefore, unadjusted p-values were reported to facilitate interpretation. To further assess the robustness of the findings and account for potential confounding, we conducted multivariable logistic regression analyses for the main outcomes, including variables such as specialty, sex, years of practice, and prior PSA training. These models allowed us to estimate adjusted associations between predictors and outcomes. The results of these analyses were consistent with the univariate findings, particularly for SDM and guideline use. In addition, applying a Bonferroni correction (α = 0.05 divided by approximately 25 comparisons; adjusted α ≈ 0.002) did not change the interpretation, as the main associations remained statistically significant.

All questionnaire items were originally measured using Likert-type scales. For descriptive and comparative analyses, some variables were grouped into broader categories to facilitate interpretation. In particular, selected variables were dichotomized into low versus high categories based on conceptual relevance. Sensitivity analyses using the original ordinal scales showed consistent results.

 Ethic statement

This study did not involve human subjects, identifiable personal data, or clinical interventions. Therefore, formal compliance with the Declaration of Helsinki was not required. Nevertheless, ethical principles for voluntary participation and data protection were followed throughout the study.

Participation in the Delphi survey was voluntary. Potential participants were invited via professional mailing lists and received information about the study objectives, procedures, and data handling. Completion of the anonymous online questionnaire (administered via Google Forms) was considered as informed consent. No personally identifiable information was collected at any stage. Institutional Review Board Statement: CEIC Sant Joan d’Alacant (20/041) on 8th January 2021.

 Results

The study included 494 clinicians, GPs (280, 56.7%) and urologists (214, 43.3%) (Table 1). The sample included 228 men (46.2%) and 257 women (52%), with a median age of 49 years (IQR: 35.8–58) and a median of 22 years of professional experience (IQR: 10–30). Most of the surveyed clinicians had received formal education regarding the PSA test (303, 61.3%). Most of the surveyed clinicians worked in the public sector (470, 95%): the urologists all worked in a hospital setting while the GPs worked in primary care centres.

10.1371/journal.pone.0349758.t001Differences in clinicians’ opinions about opportunistic PCa screening and the PSA testing according to sociodemographic variables and practice related variables.
Variables (n, %) Total How concerned are you about not detecting PCa? Importance of PCa screening? Usefulness of the PSA test for PCa diagnosis Would you recommend the PSA test to your relatives?
None or little Quite a lot or a lot p-value None or little Quite a lot or a lot p-value None or little Quite a lot or a lot p-value None or little Quite a lot or a lot p-value
Sex 0.450 0.152 0.097 0.012
Man 228 44 (24.7) 134 (75.3) 20 (8.8) 208 (91.2) 57 (34.8) 107 (65.2) 58 (33.1) 117 (66.9)
Woman 257 50 (21.6) 182 (78.4) 33 (12.8) 224 (87.2) 99 (43) 131 (57) 103 (45.6) 123 (54.4)
NA 9
Age (years) (median, IQR) 49 (35.8-58) 47 (33-56) 50 (37-59) 0.292 46 (32-57) 50 (36-58) 0.073 49 (37-57) 48 (34-58) 0.370 47 (36-57) 50 (35-59) 0.325
Years of practice (years) (median, IQR) 22 (10-30) 16 (9-26) 23 (10-30) 0.016 19 (9-28) 22 (10-30) 0.638 24 (11-30) 21 (9-30) 0.336 22 (11-30) 21 (9-30) 0.935
Regular formation received regarding the PSA test 0.001 0.213 0.007 0.350
No 119 14 (12.2) 101 (87.8) 11 (9.2) 108 (90.8) 60 (51.3) 57 (48.7) 53 (45.7) 63 (54.3)
Yes 307 77 (26.9) 209 (73.1) 42 (13.7) 265 (86.3) 98 (36.6) 170 (63.4) 112 (40.6) 164 (59.4)
NA 68
Speciality 0.168 <0.001 <0.001 ṇ<0.001
Urologist 214 27 (18.6) 118 (81.4) 6 (2.8) 208 (97.2) 5 (4) 120 (96) 13 (9.6) 123 (90.4)
General Practitioner 280 67 (24.5) 206 (75.5) 47 (16.8) 233 (83.2) 154 (55.6) 123 (44.4) 153 (56) 120 (44)
Total 494 94 (25) 324 (75) 53 (10.7) 441 (89.3) 159 (39.6) 243 (60.4) 166 (40.6) 243 (59.4)

NA: Not available; IQR: Interquartile Range; PSA: Prostate Specific Antigen; PCa: Prostate cancer.

 Evaluation of the differences in clinicians’ opinions regarding opportunistic PCa screening and PSA testing according to relevant variables

Participants expressed differing opinions regarding opportunistic PCa screening and PSA testing, according to sociodemographic variables (Table 1).

Men stated that were more likely to recommend the PSA test to their relatives than women (66.9% vs. 54.4%, p = 0.012), although there were no significant differences by sex in terms of concern about missing PCa, perceived importance of PCa screening, or perceived usefulness of the PSA test. Participants with more years of practice expressed significantly greater concern about not detecting PCa (median 23 years vs. 16 years; p = 0.016). Those who had previously received formal education about the PSA test were significantly less concerned about missing PCa (73.1% vs. 87.8%, p = 0.001) and considered the PSA test less useful for diagnosis (63.4% vs. 48.7%, p = 0.007). Urologists were significantly more likely than general practitioners to rate PCa screening as important (97.2% vs. 83.2%, p < 0.001), to consider the PSA test useful (96% vs. 44.4%, p < 0.001), and to state that they would recommend it to their relatives (90.4% vs. 44%, p < 0.001).

In the multivariable analysis, after adjusting for previous training on PSA testing, years of practice remained significantly associated with greater concern about missing PCa (aOR = 1.023; 95% CI: 1.005–1.044; p = 0.024). In addition, after adjusting for previous training on PSA testing, urologists were significantly more likely than GPs to consider PSA testing useful (aOR = 0.037; 95% CI: 0.013–0.084; p < 0.001). However, after adjusting for sex, there were no significant differences between specialties in the willingness to recommend PSA testing to relatives.

 Analysis of differences in routine practice in PSA screening for PCa by specialist area

Differences in self-reported use of PSA testing were observed between urologists and GPs (Table 2). Urologists reported recommending PSA testing at earlier stages more frequently (40–49 years: 20, 12.3% and 50–59 years: 126, 77.8%) compared to GPs (40–49 years: 10, 3.6% and 50–59 years: 89, 32%), who more frequently reported not recommending the test at all in asymptomatic patients (160, 57.6% vs 173, 39.3%), p < 0.001.

10.1371/journal.pone.0349758.t002Analysis of differences in routine practice in PSA screening for prostate cancer by speciality.
Questions Total (494) (n, %) General Practitioners (280) (n, %) Urologists (214) (n, %) p-value
At what age would you request the first PSA test in an asymptomatic man? <0.001
40-49 30 (6.8) 10 (3.6) 20 (12.3)
50-59 215 (48.9) 89 (32.0) 126 (77.8)
Over 60 22 (5.0) 19 (6.8) 3 (1.9)
Would not request 173 (39.3) 160 (57.6) 13 (8.0)
NA 54
In which age decade do you apply for the highest number of PSA requests? 0.004
40-49 2 (0.5) 0 (0.0) 2 (1.3)
50-59 119 (29.4) 75 (30.6) 44 (27.5)
60-69 264 (65.2) 152 (62.0) 112 (70.0)
70-79 20 (4.9) 18 (7.3) 2 (1.3)
NA 89
In which age decade do you think PSA is most sensitive for diagnosing prostate cancer? <0.001
40-49 24 (5.7) 17 (6.1) 7 (4.9)
50-59 135 (32.2) 76 (27.4) 59 (41.5)
60-69 157 (37.5) 95 (34.3) 62 (43.7)
70-79 28 (6.7) 17 (6.1) 11 (7.7)
NS/NC 75 (17.9) 72 (26.0) 3 (2.1)
NA 75
At what age do you think you should stop ordering PSA in a male with normal PSA values? <0.001
70 62 (14.7) 49 (17.6) 13 (9.1)
75 112 (26.5) 58 (20.8) 54 (37.8)
80 148 (35.1) 89 (31.9) 59 (41.3)
Never 32 (7.6) 23 (8.2) 9 (6.3)
None of the above 68 (16.1) 60 (21.5) 8 (5.6)
NA 72
How often would you order a PSA test for a male with a previous apparently normal level, and within the appropriate age range? <0.001
Every year or less 206 (50.6) 124 (45.6) 82 (60.7)
Every two years 127 (31.2) 84 (30.9) 43 (31.9)
Every two years or more 74 (18.2) 64 (23.5) 10 (7.4)
NA 87
If a patient actively requests the PSA test, I... 0.03
Request it without explanation. 21 (5.1) 8 (2.9) 13 (9.8)
I inform about the (dis)advantages of the test and, if indicated, request it. 259 (63.0) 171 (61.3) 88 (66.7)
I inform about the (dis)advantages of the test and request it, even if it is not indicated. 117 (28.5) 88 (31.5) 29 (22.0)
Other 14 (3.4) 12 (4.3) 2 (1.5)
NA 83
How many PSA tests per year would you order in an asymptomatic 65-year-old male with no treatment and a last test of 3 ng/ml performed one year ago? <0.001
None 116 (28.3) 104 (37.4) 12 (9.1)
One 236 (57.6) 144 (51.8) 92 (69.7)
Two 54 (13.2) 29 (10.4) 25 (18.9)
Three 4 (1.0) 1 (0.4) 3 (2.3)
NA 84
Do you offer PSA testing to men who come for another reason and are going to have a blood test? <0.001
No 253 (62.3) 204 (73.4) 49 (38.3)
Yes 153 (37.7) 74 (26.6) 79 (61.7)
NA 88
If you have decided that PSA is indicated in a particular patient: 0.423
I include it in the test without asking the patient. 108 (26.7) 75 (27.1) 33 (26.0)
I ask the patient if he/she wants the test and explain its advantages and disadvantages. 279 (69.1) 188 (67.9) 91 (71.7)
I give the patient a standardised written form/ Other 17 (4.2) 14 (5.1) 3 (2.4)
NA 90
Is the decision to order a PSA test shared with the patient? <0.001
Never/almost never 91 (22.9) 20 (7.2) 71 (59.2)
Sometimes 101 (25.4) 64 (23.1) 37 (30.8)
Often/always 205 (51.6) 193 (69.7) 12 (10.0)
NA 97

NA: Not available; PSA: Prostate Specific Antigen.

Both groups reported requesting the highest number of PSA tests primarily for patients aged 60–69 years (112, 70% vs 152, 62%, respectively). However, GPs reported a greater tendency to request PSA tests for patients aged 70–79 years compared with urologists (18, 7.3% vs 2, 1.3%, respectively; p < 0.001).

When deciding the appropriate age to stop PSA testing, GPs reported a tendency to favour stopping earlier (49, 17.6% at 70 years) compared to urologists (13, 9.1%), p < 0.001.

Urologists reported greater consistency with annual PSA testing practices than GPs (82, 60.7% vs 124, 45.6%, respectively), (p < 0.001), and significantly more likely to report routinely offering PSA tests to patients undergoing blood tests for unrelated reasons in comparison with GPs (79, 61.7% vs. 74, 26.6%, respectively) (p < 0.001). In addition, urologists reported a higher likelihood of requesting a PSA test without prior explanation when actively requested by the patient compared with GPs (13, 9.8% vs. 8, 2.9%, respectively) (p = 0.03). Urologists reported lower engagement in SDM when ordering a PSA test compared with GPs (12, 10% vs. 193, 69.7%, respectively) (p < 0.001). In the multivariable analysis, adjusting for variables that were significant in the univariate analysis (sex and specialty), GPs were significantly more likely to engage in SDM than urologists (aOR = 5.345; 95% CI: 2.793–10.568; p < 0.001).

 Differences in the information provided by the clinicians to the patients regarding the advantages and disadvantages of the PSA test

Clinicians’ self-reported knowledge and adherence to relevant guidelines varied according to specialist area (Table 3). Urologists reported greater knowledge of at least one of the following guidelines: EAU/AEU or (Preventive Activities and Health Promotion Program of the Spanish Society of Family and Community Medicine (semFYC) (PAPPS) guidelines [19] than GPs, and also a greater knowledge of the USPSTF guidelines [5] (p < 0.001 in both comparisons).

10.1371/journal.pone.0349758.t003Knowledge and use of current guidelines on early detection tests for prostate cancer.
Questions Total = 494 (n, %) General Practitioner = 280 (n, %) Urologist (214) (n, %) p value
Knowledge of the content of the following guides:
European guideline on prostate cancer (European Association of Urology), Spanish Association of Urology or Preventive Activities and Health Promotion Program of the Spanish Society of Family and Community Medicine <0.001
Yes, they know the content 206 (48.8) 64 (24.1) 142 (91)
Yes, they have read the guide, but they do not know exactly the content 59 (14) 48 (18) 11 (7.1)
Yes, they have heard of it 46 (10.9) 45 (16.9) 1 (0.6)
No, they don’t know the content 111 (26.3) 109 (41) 2 (1.3)
NA 73
US Preventive Services Task Force (USPSTF) <0.001
Yes, they know the content 130 (24.5) 44 (16.2) 59 (39.6)
Yes, they have read the guide, but they do not know exactly the content 80 (19.0) 66 (24.4) 14 (9.4)
Yes, they have heard of it 83 (19.8) 67 (24.7) 16 (10.7)
No, they don’t know the content 154 (36.7) 94 (34.7) 60 (40.3)
NA 74
Use of the available recommendations in usual practice. <0.001
Yes 236 (56.5) 97 (36.2) 139 (92.7)
No 182 (43.5) 171 (63.8) 11 (7.3)
NA 76
Change in the way they use the PSA test since the publication of the latest recommendations from the European Association of Urology 0.001
Yes 96 (24.6) 51 (19.5) 45 (34.9)
No 295 (75.4) 211 (80.5) 84 (65.1)
NA 103

NA: Not available; PSA: Prostate Specific Antigen.

Urologists also reported a higher likelihood of applying these recommendations from these organizations in their daily practice (92.7%) compared to GPs (36.2%). Despite their familiarity with the guidelines, a considerable majority of clinicians reported not having changed their PSA testing practices following the update of the EAU guidelines in 2021 (75.4% had not changed), although urologists showed a higher rate of update (34.9%) compared to GPs (19.5%).

Fig 1 presents a comparative analysis of how healthcare professionals from different specialist areas, and according to their awareness of existing clinical guidelines, report informing patients about the advantages of PSA testing. This figure shows that GPs who reported being aware of the guidelines were more likely to report informing patients with information about the benefits of PSA testing, such as early detection of PCa, than those who were not. Fig 2 focus on the disadvantages. It shows that GPs who reported awareness of the guidelines were more likely to report discussing potential disadvantages – such as overdiagnosis, false positives or unnecessary treatments – with the patients, compared to those who were not. In the multivariable analysis, adjusting for variables that were significant in the univariate analysis (sex, specialty, and previous training on the PSA test), urologists were significantly more likely to follow the guidelines than GPs (aOR = 0.046; 95% CI: 0.022–0.088; p < 0.001). In addition, previous training on PSA testing was associated with higher adherence to guidelines (aOR = 2.011; 95% CI: 1.109–3.750; p = 0.024).

10.1371/journal.pone.0349758.g001Analysis of the differences in the provision of information provided regarding the advantages of the PSA test according to the reported knowledge of available guidelines by each speciality. 10.1371/journal.pone.0349758.g002Analysis of the differences in the provision of information provided regarding the disadvantages of the PSA test according to the reported knowledge of available guidelines by each speciality. Discussion

The present study found significant differences between how GPs and urologists reported to deal with PCa opportunistic screening in Spain. In general, urologists expressed more favorable opinions toward the importance, usefulness, and recommendation of PSA testing compared to GPs. Urologists were also more inclined to initiate PSA testing in patients of younger ages, asymptomatic patients, and to test those in older age groups. Additionally, urologists reported ordering more frequent routine annual PSA tests and to offer these tests when patients had unrelated blood tests. GPs reported a higher level of engagement in SDM processes when ordering PSA tests compared to urologists. Urologists also reported a considerably higher level of knowledge regarding existing clinical guidelines, compared to GPs, and reported applying them in their daily practice more frequently. It is important to point out that knowledge of clinical guidelines was related to a greater likelihood of providing more complete and balance of information communicated to patients, regarding PSA testing. However, GPs more frequently reported to implement SDM when ordering a PSA test. This apparent paradox may be explained by several factors. First, urologists often work in more specialised clinical settings, where care is more focused on confirming diagnoses and making management decisions, which may limit opportunities for SDM [20]. Second, because they are more familiar with PCa and its consequences, they may feel more confident about the benefits of testing and therefore be less likely to actively involve patients in the decision-making process. Third, differences in professional culture may also contribute, as primary care tends to place greater emphasis on holistic care and patient-centred communication, including discussion of risks and patient preferences [21]. Importantly, this does not reflect a lack of competence, but rather highlights an opportunity to better support SDM in specialised settings, for example through improved communication tools and targeted training.

The data from our study highlights significant variability among clinicians’ self-reported practices regarding opportunistic PCa screening and attitudes towards PSA testing, influenced by sociodemographic factors and clinical specialty. Similar trends have been observed in existing literature, where clinicians’ opinions vary widely based on training, information received, and professional role [22,23]. In our study, clinicians with more years of practice showed greater concern about missing PCa, consistent with findings suggesting that experienced clinicians may rely more on routine screening to mitigate the risks of missed diagnoses [24]. In addition, clinicians who reported receiving formal education on PSA testing were less likely to express concern about underdiagnosis of PCa, which should not be interpreted as a greater inclination toward screening but rather as reflecting a more cautious and balanced perspective. This finding, together with their lower perceived diagnostic utility of the test and greater attention to communicating its limitations, suggests that education may promote a more critical appraisal of both the benefits and harms of PSA screening. In this context, while GPs appear to more consistently incorporate the communication of risks and uncertainties into clinical practice, urologists—who often work in more specialised settings—may benefit from additional support and tools to enhance patient communication, particularly regarding issues such as overdiagnosis and overtreatment [25].

Specialization substantially influenced perspectives on PSA testing, with urologists reporting a greater inclination to support the utility of PSA screening and to recommend it to relatives compared to GPs. This aligns with previous research suggesting that specialists are often advocates of routine PSA screening due to their tendency to minimize the potential risks of screening, as reflected in their differing values compared with GPs. In contrast, GPs may adopt more conservative approaches due to concerns over potential overtreatment and overdiagnosis [26,27].

Differences in self-reported routine clinical practices were also observed between urologists and GPs. Urologists reported a tendency to initiate PSA screening at younger ages, to request PSA tests more frequently, and to extend screening into older age groups compared to GPs. These patterns may be influenced by differences in guideline recommendations, such as those from the European Association of Urology guidelines, which recommend early and frequent screening practices for certain high-risk populations, in contrast to the more restrictive approach recommended by the US Preventive Services Task Force [7] or the Preventive Activities and Health Promotion Program (PAPPS) of the Spanish Society of Family and Community Medicine (semFYC) [19]. In this context, it is also important to acknowledge that different types of guideline-producing bodies may adopt distinct methodological approaches; for example, public health-oriented organisations such as the US Preventive Services Task Force aim to minimise potential conflicts of interest by limiting the direct involvement of specialists in decision-making panels [28], whereas specialty-driven guidelines may reflect a more focused clinical perspective. This represents yet another case of how differences in values and preferences can lead to divergent clinical decisions — the same evidence interpreted through different professional perspectives results in different approaches to patient care.

Self-reported knowledge and use of clinical guidelines varied between specialties. Urologists reported significantly greater knowledge of and adherence to the guidelines than GPs. GPs reported lower familiarity with the European Association of Urology guidelines, which reflect the recent recommendations for PCa screening, and the US Task Force recommendations are distant and rarely consulted in daily practice. However, clinicians who reported being familiar with the guidelines were more likely to report informing patients of the advantages and disadvantages of PSA screening, supporting previous findings that guideline awareness could improve SDM [29].

The disparities identified in the study between GPs and urologists have important implications for clinical practice, patient outcomes and health policy. Differences in self-reported attitudes, practices and knowledge of guidelines suggest the need for specific interventions aimed at improving dissemination of guidelines, clarifying recommendations and promoting consistent shared decision-making processes in both primary care and specialised urological settings. Educational programmes specifically designed to address GPs’ concerns about PSA screening and equip them with tools for effective communication with patients could help overcome these gaps. Furthermore, harmonisation of guideline recommendations across medical organisations and clear communication of their practical implications would mitigate perceived complexity and conflicts, potentially improving adherence and consistency in clinical practice. Thus, our findings underscore the importance of ongoing education and guideline dissemination to reduce practice variability and promote informed dialogues between patients and clinicians. Continued efforts to standardise PSA screening practices through professional education would also increase consistency and potentially improve patient outcomes.

The research is not without limitations. The cross-sectional design limits the ability to accurately capture practice patterns over time. In particular, while associations were observed between factors such as guideline knowledge or formal education and reported clinical behaviours, the study design does not allow us to determine whether such knowledge leads to changes in practice. Therefore, these findings should be interpreted as correlations rather than evidence of causation, and longitudinal studies would be needed to assess the direction and impact of these relationships. Reliance on self-reported data could introduce biases, potentially leading to overestimation or underestimation of actual clinical practices. Recruiting participants exclusively through scientific societies may introduce volunteer bias, as affiliated clinicians may be more engaged with continuing education, guideline updates, and professional development than non-affiliated practitioners. However, this approach provided access to a large and geographically diverse sample: in Spain, there were approximately 45,820 GPs in 2023, of whom around 20,000 are members of semFYC, and about 2,000 urologists, of whom 1,630 are members of the AEU. In addition, around 95% of clinicians in Spain work in the public sector, which is reflected in our sample. Nevertheless, the perspectives of non-affiliated or exclusively private-sector practitioners may be underrepresented. Future studies should aim to include a broader range of clinicians to enhance national representativeness. Moreover, our goal was not to achieve a proportional representation of all clinicians in Spain, but to allow a balanced comparison between general practitioners and urologists, which was the main objective of the study. Since primary care physicians outnumber urologists substantially in the Spanish health system, a proportionally representative sample would have resulted in a relatively small number of urologists, thereby limiting statistical power and reducing the ability to detect significant differences between specialties. For this reason, we set out to recruit sufficient numbers from both groups to ensure comparability in subgroup analyses. In addition, differential response rates between general practitioners and urologists may have influenced the results. However, sensitivity analyses-including specialty stratified analysis and multivariate models adjusted for key characteristics such as sex, years of practice, and prior PSA training-showed consistent results across models. The direction and statistical significance of major partnerships, particularly those related to shared decision-making and use of guidelines, remained stable, which suggests that the differential response is unlikely to fully explain the observed differences based on speciality. Moreover, given the survey’s national scope within Spain, caution must be exercised when generalizing findings internationally, considering variations in healthcare systems, clinical guidelines, and cultural factors affecting screening practices elsewhere. The response rate could not be determined, as the survey was distributed to all members of the participating scientific societies and responses were included consecutively until the required sample size was reached. This approach may introduce selection bias, as respondents could be more likely to represent a more motivated and engaged subgroup of clinicians, particularly those more interested in guideline-based practice or SDM. Consequently, the reported levels of SDM and other practices may be overestimated compared to routine clinical practice. Future studies using sampling strategies that allow calculation of response rates and broader inclusion of clinicians would improve representativeness. Nevertheless, this study includes a robust methodological framework, characterized by a well-defined sample size (n = 494) and a comprehensive questionnaire development through an expert-validated modified Delphi method, enhancing the validity and reliability of the results. Additionally, the large and diverse sample of clinicians across different age groups and experience levels further strengthens its representativeness. Missing data ranged from 11% to 21% across variables, and although analyses suggested no significant differences between respondents with complete and incomplete data, the assumption that data were missing at random cannot be fully verified. However, sensitivity analyses using complete-case data showed consistent results, suggesting that missing data are unlikely to have substantially influenced the main findings.

 Conclusions

This study underscores significant, specialty-based variations in self-reported PSA screening practices between GPs and urologists, shaped by divergent perceptions, clinical responsibilities, and familiarity with guidelines. Addressing these disparities through targeted educational initiatives, simplified and harmonized clinical guidelines, and enhanced emphasis on SDM is essential to optimizing evidence-based PCa screening, ensuring patient-centered care, and ultimately improving healthcare outcomes.

 Supporting information STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies.

(DOC)

 Questionnaire.

(DOCX)

We acknowledge the collaboration of the Spanish Society of Family and Community Medicine (semFYC) and the Spanish Association of Urology in the implementation of the survey, whose participation was essential for the development of the study.

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BMJ Open. 2018;8(1):e018009. doi: 10.1136/bmjopen-2017-018009 29362252 Spooner J, Birk M, Espinosa V, Hoag N. The times they are a-changin’: the evolution of prostate cancer screening practices and beliefs among primary care physicians in Victoria, British Columbia. Can Urol Assoc J. 2021;15(6):192–6. doi: 10.5489/cuaj.6680 33212001 Wilkes MS, Day FC, Srinivasan M, Griffin E, Tancredi DJ, Rainwater JA, et al. Pairing physician education with patient activation to improve shared decisions in prostate cancer screening: a cluster randomized controlled trial. Ann Fam Med. 2013;11(4):324–34. doi: 10.1370/afm.1550 23835818 Pickles K, Carter SM, Rychetnik L. Doctors’ approaches to PSA testing and overdiagnosis in primary healthcare: a qualitative study. BMJ Open. 2015;5(3):e006367. doi: 10.1136/bmjopen-2014-006367 25783420 Carter HB, Albertsen PC, Barry MJ, Etzioni R, Freedland SJ, Greene KL, et al. Early detection of prostate cancer: AUA guideline. J Urol. 2013;190(2):419–26. doi: 10.1016/j.juro.2013.04.119 23659877 Ngo-Metzger Q, Moyer V, Grossman D et al. Conflicts of interest in clinical guidelines: update of U.S. preventive services task force policies and procedures. Am J Prev Med. 2018;54:S70–S80. Volk RJ, Shokar NK, Leal VB, Bulik RJ, Linder SK, Mullen PD, et al. Development and pilot testing of an online case-based approach to shared decision making skills training for clinicians. BMC Med Inform Decis Mak. 2014;14:95. doi: 10.1186/1472-6947-14-95 25361614 10.1371/journal.pone.0349758.r001 Decision Letter 0 Lawal Ismaheel Academic Editor 2026 Ismaheel Lawal This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 0

29 Mar 2026

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Reviewer #1: The manuscript addresses an important and timely topic, and the data presented are of clear interest. To further strengthen the paper and enhance its clarity and impact, several aspects could be refined.

The Introduction would benefit from an updated and more comprehensive European policy framework. In particular, it would be helpful to include reference to the EUCanScreen programme and to the Council Recommendation of 9 December 2022 on strengthening prevention through early detection (2022/C 473/01). This document explicitly highlights prostate cancer screening as an area where, in light of preliminary evidence and the widespread use of opportunistic screening, countries are encouraged to adopt a gradual approach, including pilot programmes and further research. It also specifies that PSA testing, combined with MRI as a follow-up test, should be evaluated in terms of feasibility and effectiveness within organised programmes. Framing the study within this context would reinforce its relevance, as it clearly aligns with the current European call for further scientific evidence in this field.

The section on the management of abnormal findings could be further clarified by considering how incidental findings, including those potentially outside the direct scope of urology, are addressed within the proposed pathway.

While the manuscript focuses on general practitioners and urologists, it might benefit from acknowledging the broader perspective of screening governance, particularly the role of public health specialists. These professionals contribute to ensuring adherence to shared protocols, quality assurance, and informed participation, which are key elements of organised screening programmes. Other specialists such as radiologists and pathologists play also a key role. In addition, the potential involvement of professional associations and patient organisations in the co-construction of screening strategies could be briefly mentioned as a possible future development. Their inclusion in a further Delphi process, for example, might offer valuable complementary perspectives.

Some sentences in the final part of the Introduction appear slightly redundant and could be streamlined to improve readability.

The Ethics section would also benefit from clarification. As the study does not involve human subjects, identifiable data, or interventions, it may be sufficient to state that compliance with the Declaration of Helsinki was not required. In addition, further detail on the process of obtaining written informed consent for participation in the Delphi survey would improve transparency, particularly considering that the questionnaire was distributed via mailing lists and completed through an anonymous Google Form. If available, providing the consent form as supplementary material could be helpful.

From a methodological perspective, it may be useful to emphasise more clearly that the study captures self-reported practices and intentions, rather than observed behaviours. Adopting more cautious wording throughout the manuscript, including the Discussion, could help maintain consistency and avoid overinterpretation. This is particularly relevant when comparing general practitioners and urologists, who operate in different clinical contexts and interact with different patient populations. For example, the reported consistency of annual PSA testing might reflect an intention to prescribe rather than actual practice, especially among urologists working predominantly in public settings (95% of the sample), where patients are more likely to present already with (urologic) symptoms or specific clinical indications. In contrast, general practitioners are more likely to engage with the general population and preventive care, making their reported prescribing intentions more closely aligned with real-world screening practices. This distinction could be more explicitly considered when interpreting the findings.

Some results would benefit from a more nuanced interpretation. In particular, clinicians who reported receiving formal education on PSA testing appear less likely to consider the test useful for diagnosis and more likely to communicate its limitations to patients. This is a relevant finding that could be more clearly highlighted and consistently reflected in the Discussion. In this light, conclusions suggesting that educational programmes should primarily aim to increase PSA screening uptake among general practitioners may not be fully supported by the data. Rather, the findings seem to suggest that education is associated with a more cautious and balanced approach, including greater attention to the potential harms of screening.

Related to this, the statement that knowledge of clinical guidelines improves the completeness and balance of information provided to patients could be reconsidered in light of the results, which seem to indicate that clinicians more familiar with guidelines may still be less likely to discuss key aspects such as overdiagnosis, overtreatment, and the use of shared decision-making, aspects that have already contributed in the past to slow the initial enthusiasm in prostate cancer screening. Given that shared decision-making is widely recognised as essential in contexts where recommendations are not uniform, this aspect could be further explored.

In discussing variability in guidelines, it might also be useful to briefly acknowledge that different types of guideline-producing bodies may adopt different methodological approaches. For example, public health-oriented organisations (USPSTF) aim to minimise potential conflicts of interest by limiting the direct involvement of specialists in decision-making panels, whereas specialty-driven guidelines may reflect a more focused clinical perspective.

The results concerning clinicians who received formal education on PSA testing and their lower concern about underdiagnosis could be clarified, as the current phrasing may suggest a greater inclination towards screening, whereas the data appear to indicate a more cautious stance. This point is particularly important and could support a more consistent and balanced discussion. In this context, it may also be worth considering that, while general practitioners appear to integrate communication of risks more frequently, urologists, who often work in more specialised settings, might benefit from additional support and tools for effective communication with patients, particularly regarding overdiagnosis and overtreatment.

Some minor issues of consistency and clarity should also be addressed, including formatting (e.g., lines 316, 419, 432), consistent definition and use of acronyms (e.g., USPSTF, PAPSP), and uniform terminology for figures and graphs (e.g., Figure vs Graph, Figure 1A/1B).

Overall, the study provides interesting insights into this complex and evolving topic but I would suggest a more cautious and closely aligned interpretation of the findings, together with improved contextualisation and consistency to help the manuscript better reflect its strengths and enhance its contribution to the discussion.

Reviewer #2: Thank you fir submitting your work. Please find my comments:

1. Recruitment only from societies likely introduces 'volunteer bias'. Private sector / non-affiliated / remote area practitioners may be less engaged with guideline-based practices. This leads to limited national generalizability. Please address this limitation, if cannot be performed.

2. Response rate is required among the physicians invited to participate. If its too low, the cohort may reflect motivated minority, rather than typical practice. Real-world SDM % may be lower than reported. Please address this.

3. Statistical confounding: GPs and Urologists are not comparable groups, which differ not just in knowledge, but also in practice setting and patient-approach. Chi-square would likely cause unadjusted comparison. Logistic regression is recommended for SDM, PSA screening and guidelines-adherence for multiple predictors (such as specialty, sex, years of experience etc.). Is specialty significant after adjustment? This would be a true measure of specialty-based practice differences.

4. Expand on limitation of cross-sectional study: Knowledge of guidelines lead to behavior change cannot be inferred, only association can be commented upon. Please modify verbiage accordingly.

5. More knowledge but less SDM for Urologist: A powerful but underdeveloped finding of this study. Authors should give their interpretation on why this paradox exists, pertaining to their local community / culture. Such intellectual interpretation could help others to expand on public health research and education.

5. Minor grammatical corrections: GPS to GPs, UAE to EAU in table 3.

Reviewer #3: This manuscript reports findings from the PROSHADE cross-sectional survey, which examines the knowledge, attitudes, and practices (KAP) of general practitioners and urologists in Spain regarding PSA testing and prostate cancer screening. The topic is clinically relevant and timely. However, the manuscript presents several methodological limitations, reporting inconsistencies, and analytical issues that need to be addressed through major revisions before it can be considered for publication in PLOS One.

Major concerns:

It is mentioned that there are 1,630 urologists included in the AEU and 20,000 GPs in the SEMFYC. There is a large difference in sampling fractions between the two groups - 214 out of the 1,630 urologists versus 280 out of the 20,000 GPs took the survey. Response rate is not reported anywhere in the manuscript, which is a critical omission for survey research. The discrepancy in sampling fractions between urologists and GPs (13% vs. 1.4%) raises concerns about selection bias and representativeness. The authors should report response rates explicitly and discuss potential non-response bias. Consider sensitivity analyses to address differential response rates.

The authors consecutively selected the first clinicians who answered the survey. This describes a convenience sample, not a probability sample. However, the sample size calculation (lines 220-229) assumes simple random sampling to achieve 5% precision with 95% CI. This mismatch undermines the validity of the precision estimates. The authors should acknowledge that this is a convenience sample and revise claims about precision accordingly.

Tables 1, 2 and 3 demonstrate multiple chi-square tests without any correction for multiple testing. This increases the risk of Type I error. Consider applying corrections such as Bonferroni correction.

The authors mention that chi-square tests were used for all associations. However, Table 1 includes continuous variables like age and years of practice with median comparisons. Chi-square is inappropriate for continuous data. Please clarify which tests were used for continuous variables and report test statistics appropriately. For continuous data, tests of normality should be performed before choosing the appropriate test for comparison.

The analyses presented are all bivariate, comparing GPs and urologists without adjusting for other factors. Observed differences may be influenced by potential confounders such as age, sex, years of practice, or prior training. For example, if urologists are younger or more recently trained, differences may reflect generational or educational factors rather than specialty per se. The manuscript would be strengthened if the authors could conduct multivariable regression analyses that adjust for these potential confounders to assess the independent association of specialty with the outcomes of interest.

The authors assume data are missing at random without providing evidence. Missing data ranges from 11-21% across questions. No sensitivity analyses were performed. Please justify the MAR assumption with supporting analyses or conduct sensitivity analyses.

All answers were presented as Likert scale. However, Tables 2-3 show categorical/nominal response options as well. Please clarify in methods section.

Table 1 collapses Likert responses into binary categories: "none or little" versus "quite a lot or a lot" without methodological justification. This dichotomization discards information and reduces statistical power. Please justify the dichotomization approach or present ordinal analyses.

Line 72: Can a descriptive cross-sectional survey identify "associations"? This language suggests analytical epidemiology, but the design is primarily descriptive. Consider revising to "examine differences" or "compare."

Lines 366-367 states that "knowledge of clinical guidelines positively influences the completeness and balance of information" which could be interpreted as implying a causal relationship. Given the cross-sectional design of the study, causality cannot be established. It would be helpful for the authors to rephrase this statement using language that more accurately reflects an association rather than a causal effect.

Lines 421-433 covering the limitations section is brief and does not address the major methodological concerns outlined above. The authors should expand the limitations section to address the issues described above.

Moderate concern:

Although this is a KAP study, the authors did not use the ChecKAP reporting checklist, which was specifically developed for this study type and includes 46 items across 8 domains. The authors should complete and submit the ChecKAP checklist as supplementary material to ensure comprehensive reporting of all essential KAP study elements.

Minor concerns:

Formatting/typographical errors:

Line 152: Reference appears in different font/size.

Line 316: Font/size formatting inconsistency.

Lines 432-433: Font/size formatting inconsistency.

Line 337 - "uptake" should likely be "update" when referring to guideline updates.

In Table 3 - "UAE" should be "EAU" (European Association of Urology)

Line 458: Missing close bracket after SemFyc.

All tables: Use footnotes to explain abbreviations such as NA, NS/NC

Line 187: Use "cross-sectional survey" instead of "cross-sectional study."

Table 1: Clarify what "regular formation" means.

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Reviewer #2: No

Reviewer #3: Yes: Jemimah Nayar

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 10.1371/journal.pone.0349758.r002 Author response to Decision Letter 1 Submission Version 1

2 May 2026

PONE-D-26-08019

Disparities in prostate cancer screening practices among general practitioners and urologists (PROSHADE study): a cross-sectional study

Thank you very much for your comments and interest in the manuscript.

Journal requirements

- According to the journal requirements, we have included hte following sentence: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." (page 24, lines 451-453).

- In the online submission form, you indicated that “Dataset is available upon request to the authors.”. We have included the following sentence: “All relevant data are within the manuscript and its Supporting Information files. The dataset generated and analyzed during the current study is available in Zenodo at https://doi.org/10.5281/zenodo.19983225”.

Reviewer #1: The manuscript addresses an important and timely topic, and the data presented are of clear interest. To further strengthen the paper and enhance its clarity and impact, several aspects could be refined.

The Introduction would benefit from an updated and more comprehensive European policy framework. In particular, it would be helpful to include reference to the EUCanScreen programme and to the Council Recommendation of 9 December 2022 on strengthening prevention through early detection (2022/C 473/01). This document explicitly highlights prostate cancer screening as an area where, in light of preliminary evidence and the widespread use of opportunistic screening, countries are encouraged to adopt a gradual approach, including pilot programmes and further research. It also specifies that PSA testing, combined with MRI as a follow-up test, should be evaluated in terms of feasibility and effectiveness within organised programmes. Framing the study within this context would reinforce its relevance, as it clearly aligns with the current European call for further scientific evidence in this field.

We thank the reviewer for this suggestion. In line with this comment, we have revised the Introduction to incorporate an updated European policy framework. Specifically, we have included references to the EUCanScreen programme and the Council Recommendation of 9 December 2022 on strengthening prevention through early detection (introduction section, pages 5-6, lines 131-148).

The section on the management of abnormal findings could be further clarified by considering how incidental findings, including those potentially outside the direct scope of urology, are addressed within the proposed pathway.

We thank the reviewer for this comment. In response, we have expanded the section on the management of abnormal findings to address incidental findings, including those that may fall outside the direct scope of urology (introduction section, page 6, lines 159-162).

While the manuscript focuses on general practitioners and urologists, it might benefit from acknowledging the broader perspective of screening governance, particularly the role of public health specialists. These professionals contribute to ensuring adherence to shared protocols, quality assurance, and informed participation, which are key elements of organised screening programmes. Other specialists such as radiologists and pathologists play also a key role. In addition, the potential involvement of professional associations and patient organisations in the co-construction of screening strategies could be briefly mentioned as a possible future development. Their inclusion in a further Delphi process, for example, might offer valuable complementary perspectives.

We thank the reviewer for this suggestion. In response, we have included a paragraph in the manuscript to acknowledge the broader governance perspective of organised screening programmes beyond the roles of general practitioners and urologists. (introduction section, page 7, lines 176-185).

Some sentences in the final part of the Introduction appear slightly redundant and could be streamlined to improve readability.

We thank the reviewer for this observation. In response, we have revised the final part of the Introduction to remove redundant sentences and improve clarity and readability.

The Ethics section would also benefit from clarification. As the study does not involve human subjects, identifiable data, or interventions, it may be sufficient to state that compliance with the Declaration of Helsinki was not required. In addition, further detail on the process of obtaining written informed consent for participation in the Delphi survey would improve transparency, particularly considering that the questionnaire was distributed via mailing lists and completed through an anonymous Google Form. If available, providing the consent form as supplementary material could be helpful.

We thank the reviewer for this suggestion. In response, we have revised the Ethics section to clarify that the study does not involve human subjects, identifiable personal data, or clinical interventions, and therefore formal compliance with the Declaration of Helsinki was not required. We have also expanded the description of the informed consent process to improve transparency. The revised text now specifies that participants were invited via professional mailing lists, received detailed information about the study, and that completion of the anonymous online questionnaire (administered through Google Forms) was considered as provision of informed consent. (Material and method section, page 13, lines 346-354).

From a methodological perspective, it may be useful to emphasise more clearly that the study captures self-reported practices and intentions, rather than observed behaviours. Adopting more cautious wording throughout the manuscript, including the Discussion, could help maintain consistency and avoid overinterpretation. This is particularly relevant when comparing general practitioners and urologists, who operate in different clinical contexts and interact with different patient populations. For example, the reported consistency of annual PSA testing might reflect an intention to prescribe rather than actual practice, especially among urologists working predominantly in public settings (95% of the sample), where patients are more likely to present already with (urologic) symptoms or specific clinical indications. In contrast, general practitioners are more likely to engage with the general population and preventive care, making their reported prescribing intentions more closely aligned with real-world screening practices. This distinction could be more explicitly considered when interpreting the findings.

Thank you to the reviewer for this comment. In response, we have reviewed the manuscript to emphasize more clearly that findings reflect self-declared practices and intentions rather than directly observed clinical behaviors. In addition, we have expanded the Discussion to better contextualize the comparison between general practitioners and urologists. The revised text highlights differences in their clinical settings and patient populations, noting that urologists (predominantly working in public and specialized care) are more likely to see patients with specific symptoms or indications, while general practitioners are more committed to preventive care and screening at the population level. This distinction is now explicitly taken into account when interpreting the findings, particularly with respect to PSA test patterns.

The corresponding changes have been incorporated throughout the manuscript:

- Page 3: lines 78; 79; 80; 82.

- Page 4: line 91.

- Page 16: lines 407; 417.

- Page 17, lines 431-433; 437-440; 441; 444; 445; 448-451.

- Page 21: lines 485; 486; 491; 493; 498; 500; 502.

- Page 25: lines 558; 564; 565.

- Page 26: lines 589; 608.

- Page 27: lines 623; 624; 641; 642; 643

- Page 28: lines 660; 66; 665.

- Page 31: line 741.

Some results would benefit from a more nuanced interpretation. In particular, clinicians who reported receiving formal education on PSA testing appear less likely to consider the test useful for diagnosis and more likely to communicate its limitations to patients. This is a relevant finding that could be more clearly highlighted and consistently reflected in the Discussion. In this light, conclusions suggesting that educational programmes should primarily aim to increase PSA screening uptake among general practitioners may not be fully supported by the data. Rather, the findings seem to suggest that education is associated with a more cautious and balanced approach, including greater attention to the potential harms of screening.

Thank you for this comment. We agree that this is an important aspect of our findings that deserves clearer emphasis in the Discussion. In line with your suggestion, we have revised the manuscript to better highlight that clinicians who reported receiving formal education on PSA testing were less likely to consider the test useful for diagnostic purposes, more likely to communicate its limitations to patients, and less concerned about under-diagnosis of prostate cancer. (Discussion section, page 26, lines 596-606).

Related to this, the statement that knowledge of clinical guidelines improves the completeness and balance of information provided to patients could be reconsidered in light of the results, which seem to indicate that clinicians more familiar with guidelines may still be less likely to discuss key aspects such as overdiagnosis, overtreatment, and the use of shared decision-making, aspects that have already contributed in the past to slow the initial enthusiasm in prostate cancer screening. Given that shared decision-making is widely recognised as essential in contexts where recommendations are not uniform, this aspect could be further explored.

Thank you for your comment. We have included a detailed discusión of this point comparing urologists and GPs (Discussion section pages 25-26, lines 571-588).

In discussing variability in guidelines, it might also be useful to briefly acknowledge that different types of guideline-producing bodies may adopt different methodological approaches. For example, public health-oriented organisations (USPSTF) aim to minimise potential conflicts of interest by limiting the direct involvement of specialists in decision-making panels, whereas specialty-driven guidelines may reflect a more focused clinical perspective.

Thank you for this suggestion. We agree that acknowledging differences in the methodological approaches of guideline-producing bodies adds important context to the observed variability in clinical practices. In response, we have revised the paragraph to include a sentence noting that public health-oriented organisations, such as the USPSTF, often aim to minimise potential conflicts of interest by limiting specialist involvement in decision-making panels, whereas specialty-driven guidelines may reflect a more focused clinical perspective. (Discussion section page 27, lines 632-637).

The results concerning clinicians who received formal education on PSA testing and their lower concern about underdiagnosis could be clarified, as the current phrasing may suggest a greater inclination towards screening, whereas the data appear to indicate a more cautious stance. This point is particularly important and could support a more consistent and balanced discussion. In this context, it may also be worth considering that, while general practitioners appear to integrate communication of risks more frequently, urologists, who often work in more specialised settings, might benefit from additional support and tools for effective communication with patients, particularly regarding overdiagnosis and overtreatment.

Thank you for the comment. We have revised the section to clarify that these clinicians were, in fact, less concerned about underdiagnosis while simultaneously demonstrating a more cautious and balanced perspective, including greater awareness of the limitations and potential harms of screening. Taking into account this comment and the previous one, this interpretation is now more aligned with the data and presents a more consistent perspective. (Discussion section, page 26, lines 596-606).

Some minor issues of consistency and clarity should also be addressed, including formatting (e.g., lines 316, 419, 432), consistent definition and use of acronyms (e.g., USPSTF, PAPSP), and uniform terminology for figures and graphs (e.g., Figure vs Graph, Figure 1A/1B).

Done.

Overall, the study provides interesting insights into this complex and evolving topic but I would suggest a more cautious and closely aligned interpretation of the findings, together with improved contextualisation and consistency to help the manuscript better reflect its strengths and enhance its contribution to the discussion.

Thank you for this overall assessment. We agree with the need for a more cautious and closely aligned interpretation of the findings. In response, we have revised the manuscript to ensure that the conclusions more accurately reflect the data, avoiding overinterpretation and better emphasising the nuances observed.

Reviewer #2: Thank you fir submitting your work. Please find my comments:

1. Recruitment only from societies likely introduces 'volunteer bias'. Private sector / non-affiliated / remote area practitioners may be less engaged with guideline-based practices. This leads to limited national generalizability. Please address this limitation, if cannot be performed.

Thank you for this comment. We acknowledge that recruiting participants exclusively through scientific societies such as the Spanish Association of Urology (AEU) and the Spanish Society of Family and Community Medicine (semFYC) may introduce a degree of volunteer bias. Clinicians affiliated with these organisations could be more likely to be more engaged with continuing education, guideline updates, and professional development activities than non-affiliated practitioners. At the same time, it is important to contextualise our sampling approach. In Spain, there were approximately 45,820 GPs in 2023, of whom around 20,000 are members of semFYC. Similarly, there are approximately 2,000 practising urologists in Spain, of whom 1,630 are members of the AEU. Therefore, although not fully representative, recruitment through these societies allowed access to a large and geographically diverse pool of clinicians. The aim of this approach was to facilitate participation from different regions across Spain. In addition, approximately 95% of clinicians in Spain worked in the public sector. We have addressed this limitation in the revised manuscript and highlighted the need for future studies to include a broader and more diverse sample of practitioners to enhance national representativeness. (Discussion section, page 29, lines 690-700).

2. Response rate is required among the physicians invited to participate. If its too low, the cohort may reflect motivated minority, rather than typical practice. Real-world SDM % may be lower than reported. Please address this.

Thank you for this comment. We agree that the response rate is a relevant aspect when interpreting the representativeness of the findings. In our study, the survey was distributed to all members of the participating scientific societies (AEU and semFYC), and we included consecutively the first responses received until the required sample size was reached. Based on our sample size calculation, a minimum of 384 participants was needed to ensure adequate precision, and we ultimately included 494 clinicians. However, we acknowledge that this approach does not allow for the calculation of a precise response rate and may introduce selection bias. It is possible that clinicians who chose to respond were more motivated, more engaged with guideline-based practices, or more interested in shared decision-making (SDM), which could lead to an overestimation of its implementation in routine practice. As such, the reported levels of SDM may not fully reflect real-world practice among all clinicians. We have addressed this limitation in the revised manuscript by explicitly acknowledging the potential for selection bias. Future studies using sampling strategies that allow for response rate estimation and broader inclusion of clinici

Submitted filename: PONE.docx

 10.1371/journal.pone.0349758.r003 Decision Letter 1 Lawal Ismaheel Academic Editor 2026 Ismaheel Lawal This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 1

5 May 2026

Disparities in prostate cancer screening practices among general practitioners and urologists (PROSHADE study): a cross-sectional study

PONE-D-26-08019R1

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 10.1371/journal.pone.0349758.r004 Acceptance letter Lawal Ismaheel Academic Editor 2026 Ismaheel Lawal This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PONE-D-26-08019R1

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