Do Swiss urologists and Swiss internists screen themselves and their relatives for prostate cancer? A questionnaire study

295 (response rate: 64%) urologists and 893/7400 (response rate: 12%) internists participated in the survey. Of the participants, 297/1083 (27.4%) were female. Male urologists >50 years of age screened themselves more often than male internists >50 years of age (89% vs 70%, p <0.05). Furthermore, urologists re-ported recommending screening statistically significantly more often than internists to their brother, father or partner regardless of their sex (men: 38.1% vs 18.5%; p <0.05; women: 81.8% vs 32.2%; p <0.05). CONCLUSIONS: Most participating male physicians >50 years of age have screened themselves for prostate cancer. Furthermore, PSA screening of relatives was significantly associated with the urology specialty. The reasons physicians screen themselves substantially more often than the public and why male and female urologists as well as male internists perform PSA screening more frequently in their private environment than female internists should be further examined


Introduction
The widespread adoption of prostate-specific antigen (PSA) screening is controversial.The PLCO (Prostate, Lung, Colorectal and Ovarian) trial found no difference in prostate cancer-specific survival after 7 years between patients who underwent annual PSA screening and those under usual care [1].As a result, the US Preventive Service Task Force (USPSTF) advised against population-wide PSA screening in 2012 [2].However, the European Randomised Study of Screening for Prostate Cancer (ERSPC) could demonstrate a reduction in prostate cancer mortality while increasing the detection of clinically insignificant cancer [3].This conflicting evidence led the Swiss Society of General Internal Medicine (SSGIM) to emphasise the importance of a thorough discussion of the risks and benefits before conducting a PSA screen as part of its 'smarter medicine' initiative in 2014.This emphasis on shared decision-making (SDM) is consistent with the guidelines set forth by the European Association of Urology (EAU) and the American Urological Association [4][5][6].In 2018, the USPSTF revoked its recommendation against PSA screening, favouring individualised PSA screening and the EU updated its "Europe's Beating Cancer Plan" in 2022 and initiated programmes to formally endorse PSA screening in men up to the age of 70 years [7][8].
It is estimated that between 31% and 50% of Swiss men undergo opportunistic PSA screening [9][10].In an opportunistic screening setting, men are either screened on their own initiative or on their physician's recommendation.Therefore, the physician's attitude towards PSA screening is essential.To capture how physicians weigh the risks and benefits of PSA screening, we conducted an online survey about how Swiss internists and urologists screen themselves and their relatives.The primary aim was to assess whether personal PSA screening behaviour differed between urologists and internists and by the sex of the physician.

Methods
The survey for this study was collaboratively designed by all the authors, either urologists or internists, ensuring comprehensive coverage of the relevant aspects and unbiased wording.The aim was to maximise the response rate by creating a user-friendly survey.To achieve this, the survey was designed so that it would take only two minutes for participating physicians to complete all eight questions.It was created using the software Alchemer, formally known as SurveyGizmo (Alchemer, Colorado, USA).
The invitation to participate in the online survey was sent by email in 08/2020 to all members in the registries of the Swiss Society of Urology (SSU) and the SSGIM.It could be answered anonymously in any of the Swiss national languages, namely German, French or Italian.The survey consisted of demographic questions about age, sex, medical specialty and work setting.Personal PSA screening behaviour was assessed using questions about if and at what age the physicians had screened themselves, their fathers, brothers and partners.If they answered that they had performed screening, they were asked whether shared decision-making was done beforehand and whether there was a positive family history of prostate cancer in first-degree relatives.For the complete survey, see the appendix.A reminder to participate in the survey was issued in 09/2020, and the survey was closed six weeks later.None of the respondents received any financial or non-monetary benefits.The survey database only collected responses if all eight questions had been answered.
In order to compare personal use of PSA screening, respondents were divided into groups based on their sex and specialty.Furthermore, each of the groups was stratified by age into the following strata: <40 years, 40-49 years, 50-59 years, 60-69 years and ≥70 years.Data entry and visualisation were done using Microsoft Excel (2016 versions; Microsoft Corporation, Redmond, Washington, USA).Categorical and continuous variables were compared using the Chi-squared test and t-test, respectively.A value of ɑ <0.05 was defined as statistically significant.Statistical analysis was performed using R 3.6 software (R Foundation, Vienna, Austria).

Ethics statement
This survey study adhered to the principles of the Declaration of Helsinki.
The mean age at the time of self-screening and screening of brothers were statistically significantly lower in urologists than internists (self: 47.6 [95% CI: 46.4-48.8]vs Overall, family history was positive in 23% of the screened men.Participants with positive family history were younger at the time of self-screening than those with a negative family history (mean age: 50.4 vs 52.7 years; p <0.05).However, family members with a positive family history were not statistically significantly younger at the time of screening than those without (mean age of fathers: 59.6 vs 61.0 years, p = 0.40; brothers: 50.7 vs 51.8 years, p = 0.41; partners: 47.2 vs 53.6 years, p = 0.17).
Overall, PSA screening activity (screening of father, brother, partner or, if male, themselves) was statistically significantly higher in male physicians than in female physicians, irrespective of their specialty (63.3% vs 35.9%; p <0.05) and in urologists than in general internists, regardless of  their sex (men: 77.4% vs 59.5%; p = 0.001; women: 81.8% vs 32.2%; p <0.05).PSA screening activity tended to be higher in older respondents.PSA screening was more frequently reported in the personal environment of urologists, compared to internists, across all age groups (figure 3).
Screening activity also differed according to the work setting of the participating physicians: physicians working at an academic centre were the least likely to have screened themselves or their fathers, brothers and partners (regional/ other hospital 65.1%, private practice 55.8%, cantonal hospital 55.2%, academic centre 43.1%; p <0.05).
Compared to the general population of Switzerland, the survey underrepresents French-speaking (survey: 18.6% vs population: 22.1%) and Italian-speaking regions (survey: 1.7% vs population: 8.2%); thus, the German-speaking region is overrepresented in the survey (survey: 79.8% vs population: 62.0%) [11].Between the language groups, the distribution of internists and urologists, as well as female and male respondents, was even (p = 0.25) and overall PSA screening activity did not differ (p = 0.64).

Discussion
Given the low specificity of the PSA test and the substantial morbidity associated with diagnostic workup and active treatment, PSA-based screening for early detection of prostate cancer remains a controversial topic [12][13].Although technological advances decreased the morbidity of active treatment, functional disabilities after surgery or radiotherapy significantly reduce the quality of life of the affected patients [14][15][16][17][18].However, recent data show a reduction in prostate cancer-specific mortality with PSA screening and suggest that the number needed to screen to avoid one cancer-specific death may be lower after longer follow-up [19][20].Additionally, wider implementation of surveillance strategies instead of direct treatment is potentially mitigating the morbidity of active treatment regimens [19].Therefore, in 2018 the recommendation against PSA screening was revoked by the USPSTF in favour of an individualised PSA screen based on SDM and in 2022 the EU started endorsing PSA screening in men up to the age of 70 years [7][8]21].Accordingly, in Switzerland, the "smarter medicine" initiative of the SSGIM emphasises the importance of SDM before conducting a PSA screen, such that it is the well-informed patient who decides whether to undergo screening.Our study suggests that the majority of male physicians >50 years of age, regardless of their spe-

Original article
Swiss Med Wkly.2023;153:40115 cialties, prioritised the potential benefits of PSA screening over the associated risks and screened themselves for prostate cancer, surpassing the screening rates observed for the Swiss population by a substantial margin.Additionally, urologists, regardless of sex, have reported a higher frequency of conducting PSA screening in their personal environment compared to internists.
Disparities in access to screening programmes in an opportunistic screening setting are well documented [9][10].
Men with a higher socioeconomic status and men who visited a general practitioner in the last 12 months undergo PSA screening more often [10].Furthermore, physicians can also heavily influence men's decision to undergo PSA screening [17].Two recent studies investigated the selfscreening behaviour of physicians as a surrogate for their personal attitude towards PSA screening.A survey conducted among genitourinary cancer specialists in Canada, the United States, Australia, New Zealand, and Central and South America in 2018 showed a self-screening rate of 90% in physicians older than 55 years [22].Although 896 physicians participated in the study, the response rate is unknown, so its results have to be interpreted with caution due to a possible selection bias.A 2019 German survey investigated the difference between general internists' and urologists' intention to undergo PSA self-screening once they reached 50 years of age [23].The responding urologists stated in 80% of cases that they already underwent PSA screening or had the intention to undergo PSA screening in the future compared to 55% of the general internists, but both cohorts had a very low response rate of <7% [23].
In our nationwide study, 64% of urologists and 12% of general internists completed the survey, representing the most extensive study about the personal PSA screening behaviour of physicians conducted to date.We were able to demonstrate significant specialty-specific PSA self-screening differences in male physicians over 50 years of age.While urologists screened themselves in 89% of cases, 70% of internists performed PSA self-screening.It is noteworthy that self-screening activity in both groups of physicians far exceeded the estimated PSA screening frequency of 31% to 50% in the general male population [9][10].This significant gap could be explained by differences between physicians and patients in weighing the risks and benefits of PSA screening; a selection bias whereby proscreening physicians were more likely to participate; or a general public that is uninformed or misinformed about PSA screening.Unlike colorectal or breast cancer screening, PSA screening is not endorsed by the Swiss Federal Office of Public Health, nor does a national information campaign to advocate PSA screening exist, although the number needed to screen for breast and prostate cancer are comparable [19,[24][25].
Discrepancies in offering cancer screening to patients depending on the physician's sex have been documented.It has been shown that female physicians are more likely to screen patients for breast, cervical and colon cancer, whereas male physicians are more likely to offer PSA screening to patients [26][27].However, our results only partially support these findings.Although female internists were the least active group in recommending PSA screening to family members, female urologists were shown to be the most active subgroup in terms of recommending PSA screening to family members.Female internists were the only subgroup that did not recommend PSA screening to their relatives more often than the estimated screening frequency of the Swiss male population.On the other hand, urologists, regardless of their sex, as well as male internists had a significantly higher personal PSA screening activity than the general public.A possible explanation for the higher screening rate among urologists and male physicians is that treating prostate cancer patients each day or being at risk of developing prostate cancer may increase personal screening activity among physicians.It is especially noteworthy that urologists who are both confronted with the morbidity of prostate biopsies and the treatment of prostate cancer but also with palliative prostate cancer care on a daily basis seem to favour screening for themselves and their relatives.
A first-degree family history for prostate cancer is known to increase the risk of prostate cancer significantly [28][29].Therefore, the EAU recommends offering PSA screening to men with a positive family history at the early age of 45 years.While participants with a positive family history practiced PSA self-screening at a younger age reflecting adherence to current guidelines, a positive family history did not lead to an earlier screening of relatives.
The altered 2012 recommendation of the US preventive services task force was implemented faster in the academic setting, where PSA screening was subsequently less often performed than in the non-academic setting [30][31].Although the recommendation has since been revoked, in our study an academic work setting was still associated with lower personal PSA activity compared to physicians working in private practice or a non-academic hospital.
This study has its limitations.First, it is unknown whether there is an association between the self-screening of physicians and screening of their patients in clinical practice.Furthermore, our survey was voluntary and might have led to a selection bias in favour of physicians interested and presumably more active in PSA screening, which may have resulted in higher screening rates.Finally, as in all surveys, our study results are based on self-reporting.

Conclusion
Twice as many physicians are screening themselves for prostate cancer compared to the Swiss male population.Furthermore, PSA screening activity in the personal environment is associated with the urology specialty and being a male physician.Urologists perform PSA screening at a younger age and more often for themselves and their family members than internists.Assuming that personal PSA screening behaviour is indicative of the disposition to offer PSA screening to men at risk of prostate cancer, the reason for these specialty-and sex-specific differences should be further examined.o Oui, pour mon père.À l'âge de ... ans.

Figure 1 :
Figure 1: Comparison of self-screening frequency for prostate cancer between urologists and internists.The data are stratified into different age groups.

Figure 2 :
Figure 2: Analysis of the differences in frequency between urologists and internists in recommending PSA screening to their brothers, fathers or partner.The frequencies are presented separately for females (A) and males (B) and grouped by age.

Figure 3 :
Figure 3: Subgroup analysis of respondents by sex and specialty depicting the frequency of general PSA screening activity (screening themselves [if male] or their fathers, brothers or partners) stratified by age.
Swiss Med Wkly.2023;153:40115 Swiss Medical Weekly • www.smw.ch• published under the copyright license Attribution 4.0 International (CC BY 4.0) Acquisition, analysis, or interpretation of data: All authors.Drafting of the manuscript: ST, SK, SR.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: WM.Administrative, technical, or material support: SR.Supervision: SR.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Êtes-vous membre ordinaire de la SSMIG?Cela signifie que vous détenez le titre de spécialiste en Médecine Interne Générale et que vous travaillez toujours.