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).

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.

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. Differences in clinicians’ opinions about opportunistic PCa screening and the PSA testing according to sociodemographic variables and practice related variables.

https://doi.org/10.1371/journal.pone.0349758.t001

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.

Download:

• PNG
  larger image
• TIFF
  original image

Table 2. Analysis of differences in routine practice in PSA screening for prostate cancer by speciality.

https://doi.org/10.1371/journal.pone.0349758.t002

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).

Download:

• PNG
  larger image
• TIFF
  original image

Table 3. Knowledge and use of current guidelines on early detection tests for prostate cancer.

https://doi.org/10.1371/journal.pone.0349758.t003

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).

Download:

• PNG
  larger image
• TIFF
  original image

Fig 1. Analysis 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.

https://doi.org/10.1371/journal.pone.0349758.g001

Download:

• PNG
  larger image
• TIFF
  original image

Fig 2. Analysis 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.

https://doi.org/10.1371/journal.pone.0349758.g002

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

Acknowledgments

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.