PONE-D-23-14507General practitioners' perspectives on statutory skin cancer screening – a questionnaire-based cross-sectional survey in GermanyPLOS ONE

Dear Dr. Reinhardt,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please find attached two reviews that may guide your revision. Please pay high attention to the individual concerns, particularly with the extent of validity of your findings.

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Felix G. Rebitschek

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

thank you very much for this interesting work on skin cancer screening. Considering the GPs perspective on the German statutory skin cancer screening is an important topic in order to also be able to assess the quality of the screening and derive future recommendations. Therefore, I rate the presented study positively, but think that it needs some major revision before publication. Overall the paper remains facile, specially in discussion and conclusion and the following comments should be considered:

- Information on the validity of the study should be provided. Even though representativeness is not sought, comments on needed power and sample size would be good. For assessing the informative value of the study, providing numbers of the total population in terms of age, gender and, if possible, years of experience for both regions to relate them to the study participants would be necessary. In addition, it would be important to know whether the characteristics mentioned differ between the two study regions in Bavaria and Saxony. The limited statistical representativeness should also be discussed.

- In the subgroup comparisons, the mean ranks should be given.

- The qualitative results presented appear to be more of a summary of the comments mentioned and not really a dedicated content analysis. A revision should take place here.

- The discussion should be revised and be more comprehensively. It would be very useful to compare the results of skin cancer screening from the patient's point of view with the subjective perception of the GPs considering current studies on this (see e.g. Görig et al 2021). Overall, the significant results of the subgroup differences remain unconsidered.

- Since the 8-hour training is mentioned several times, some background information should be provided. For example, that the GPs and dermatologists complete the same training, that the content of the training is determined by the KFR and what content is taught there.

In addition, the conclusion demands that uncertainties and the use of a dermatoscope should be addressed in the training, which is both already part of the training, as far as I know. In addition, a refresher course and an evaluation are recommended. Such an evaluation has always existed and there was also a refresher, but it was discontinued due to low demand. Therefore, a mandatory refresher specified by the KFE may be more useful to be discussed.

Reviewer #2: This is a well-written manuscript on the perspective of skin cancer prevention programs, which are essentially carried and implemented by primary care physicians. It can be assumed that due to the high quantitative demand the care of the people would not be guaranteed by the dermatologists alone. Already in 2014, a Schäfer et al. showed that tumor thickness is significantly higher in rural areas, in areas where specialist care is critical and will be increasingly so (1). Against this background, the present work is of political interest even if the geographical area as well as the participation is limited, but should emphasize this importance even more.

Introduction

- Are there any data about the number of performed screenings in Saxony and Bavaria by either general practitioners or dermatologists? This would be an interesting information.

Methods

Methods and statistics are described properly.

Discussion and conclusion

- The low participation of physicians has already been mentioned, and presumably physicians critical of screening in particular did not participate. This should be taken into account.

- Where possible, data on the frequency of screening in the two states should be related to the physicians surveyed and their proportion of screenings.

In summary, the paper addresses the perspective of general practitioners towards Skin Cancer Screening. Due to the geographic selection of two metropolitan regions, this is not a fully representative sample, but it nevertheless provides interesting information about the perspective of general practitioners.

(1) Schäfer I, Reusch M, Siebert S, Spehr C, Augustin M: Versorgungsmerkmale des Basalzellkarzinoms in Deutschland: Die Rolle von Versichertenstatus und sozio-demographischen Faktoren. J Dtsch Dermatol Ges. 2014

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PONE-D-23-14507.docx

PONE-D-23-14507R1General practitioners' perspectives on statutory skin cancer screening – a questionnaire-based cross-sectional survey in GermanyPLOS ONE

Dear Dr. Reinhardt,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 21 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Felix G. Rebitschek

Academic Editor

PLOS ONE

Additional Editor Comments:

Thank you very much for your submission with important results about how GPs inform patients and how they conduct dermatology standard examinations in the real world, and for addressing the reviews!

A couple of issues yet need more elaboration.

The following refers to the revision with track changes:

Major:

- It is not clear why you study what you study. Please show how you derive

o why you study, how the GPs perform/conduct the screening sessions, and, similarly,

o why you study their patient information strategies (what is here the desirable norm for comparison, are there deviations from informed screening decision making)?

o why you study their attitudes (evaluation)?

- The method leaves lacks that need to be filled for some reproducibility

o It is very good that the questionnaire is attached. The section “survey”, typically “Measures”, should nevertheless explain better what they different parts are about. This should be comprehensible without the appendix. Was this instrument validated, or used before? Was it pre-tested? If not, how it was developed? Also, how were qualitative data measured?

o How did you recruit with the help of the contact list (mailings)? How it was conducted (paper-and-pencil)? Was the procedure fixed, or could they scroll over the full survey back and forth?

o Qualitative analysis plan is underspecified; for instance I cannot infer the measures for assuring quality; please check PLOSONE here: Qualitative research studies should be reported in accordance to the Consolidated criteria for reporting qualitative research (COREQ) checklist or Standards for reporting qualitative research (SRQR) checklist.

o Because it is a survey study that aims to represent experts in Germany, we should get an indication of

� How successful was recruitment, given population; recruitment and eligibility flowchart would be very helpful.

� How representative was your sample (table 1), compared with the population of GPs in those states, or at least, in Germany, e.g. in terms of gender (an additional column with those data would be useful)?

- One can stress that the key results lie in the compliance with how to inform patients prior to examination (e.g., guidelines on evidence-based health communication) and how to conduct skin cancer examinations for purpose of screening (e.g., dermatology guidelines). Accordingly,

o You could also change Figure 1 to the analysis of proportions (I always…) This would be consistent to Figure 2 and supportive to the function of a visual (“patterns”) – complex ranking data as here could go with a table.

o Calculate (particularly with regard to further subgroup analysis) the proportions of those, who do not fully inform, and those who do not fully conduct. This stresses the need for intervention as you discuss it already.

- Subgroups: Because there was no preregistration and particularly no statistical hypotheses, please adjust alpha for multiple testing (depending on the number of your comparisons there). Furthermore, I would suggest to conduct those subgroup analyses preferably with the proportion of those who “always” did something (more robust!)

- Check reporting of qualitative results against Consolidated criteria for reporting qualitative research (COREQ) checklist or Standards for reporting qualitative research (SRQR) checklist, e.g. how many said something “was described as not relevant”…?

Discussion

- This should come back to the arguments that underlie your study motivation (see first point above).

Minors

- Suggestion to generally keep the order of your results section across the manuscript, first writing about “Informing patients” and then “Performing screening” (as it would be a the GP’s office)

- Consistent capitalisation across tables and figures and their elements please

- Consistent use of SCS across Figure captions and manuscript

- There are very important statements which do not have a reference, but which are result of the study, nor general knowledge

o L.53,54

o L.61/62

o L. 263/264

o L. 269 – could you check real-world materials for this aspect?

Abstract

- available = available free of charge?

- Objective: How = how comprehensive

- What other issues… This needs to be more concrete. What did you want to find out? How they inform patients?

Introduction:

- Do ref 2,3 control for screening programme introductions?

- Please add a sentence (based on the best available evidence) about benefits and harms of skin cancer screening for the general population from 35 years

- L.70-73, please provide the baseline numbers (of GPs and dermatologists)

Methods

- Please check order of sections against PLOSONE guidelines; also study population could go to the Methods

- Funding statement comes separately

- Delta is between absolute means, if so, expected effect size? To which outcome was this expectation referred?

Results

- L.160 , n=1?

- For your quantitative sample-based results from which you would like to generalise in the discussion, you need to provide uncertainty information (e.g. confidence intervals)

Discussion

- L. 319 “in which the uncertainties…” could be skipped here,because this is only a sub-aspect

- The construct validity does not depend on the sample; explain why recall bias affect construct validity?

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you very much for your response and the consideration of my comments. They have all been addressed adequatly.

Reviewer #3: I am coming to this manuscript as a new reviewer following revision by the authors. The authors appear to have addressed the comments from the previous reviews in a thorough and satisfactory manner. I have one minor comment, which is that it would be helpful to understand whether the training explicitly addresses which areas of the body should be screened for skin cancer. The authors highlight their findings about which areas of the body are less frequently screened by survey respondents, but they also mention that skin cancer is less frequent in those areas. It would be useful to understand the degree to which this is part of the training.

My other comment is on data availability. The authors mention have made the survey instrument and categorization scheme available, but this is insufficient to reproduce the results. If it is possible to make an anonymized file of survey responses available, the authors should do so, or explain the restrictions that don't allow them to make this data available.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: No

**********

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-23-14507R2General practitioners' perspectives on statutory skin cancer screening – a questionnaire-based cross-sectional survey in GermanyPLOS ONE

Dear Dr. Reinhardt,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 02 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Felix G. Rebitschek

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for your substantial and detailed revision!

One point remains concerning the Figures 2 and 3.

As I pointed out before about text. If the authors want to report conclusions about the population of GPs practising SCS, sample-based data should not be reported without uncertainty estimates in the figures. Without those clarifications figures could be easily misinterpreted.

If this is addressed, the manuscript can be published.

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

General practitioners' perspectives on statutory skin cancer screening – a questionnaire-based cross-sectional survey in Germany

PONE-D-23-14507R3

Dear Dr. Reinhardt,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Felix G. Rebitschek

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: