-->PONE-D-26-08019-->-->Disparities in prostate cancer screening practices among general practitioners and urologists (PROSHADE study): a cross-sectional study-->-->PLOS One

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Reviewers' comments:

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Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->5. Review Comments to the Author

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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 #1: No

Reviewer #2: No

Reviewer #3: Yes: Jemimah Nayar

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

PONE-D-26-08019R1

Dear Dr. Lumbreras,

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.

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Kind regards,

Ismaheel Lawal, MD, PhD

Academic Editor

PLOS One

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