Vol.2, No.11, 1312-1315 (2010)
doi:10.4236/health.2010.211195
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
Health
Openly accessible at
Determinants of primary care physicians’ practice of
prostate cancer counseling and screening
Danny M. Rabah, Mostafa A. Arafa*
King Saud University, Princess Al Johara Al Ibrahim Center for Cancer research, Riyadh, Saudi Arabia; *Corresponding Author:
Received 5 August 2010; revised 12 August 2010; accepted 31 August 2010.
ABSTRACT
Objective: The objective was to examine prac-
tices of primary care physicians and its deter-
minants towards prostate cancer screening. Me-
thods: Data was obtained from 204 primary care
physicians using self-reports of prostate cancer
screening practices, knowledge, attitudes to-
wards prostate cancer screening. Results: near-
ly half of the respondent (54.7%) were practicing
counseling and referring prostate cancer patients.
The mean correct knowledge score was 54.3%,
their attitude was not strong; the only statement
that nearly seventy percent of physicians agreed
upon was about the value of screening, however,
the reliability and evidence to support DRE &
PSA were in question. Knowledge and attitude
were found to be the most significant predictors
that determine physicians’ self practice. Con-
clusion: Background information and attitudes
are important determinants of physicians’ prac-
tice behavior towards prostate cancer counsel-
ing and referral in our study.
Keywords: Cancer Prostate; Counseling;
Screening
1. INTRODUCTION
Prostate cancer (PC) is the second leading cause of
cancer death nationwide for men over age 60 years. Cur-
rently, there is no scientific consensus on effective stra-
tegies to reduce the risk of PC [1]. Additionally, there is
no agreement on the effectiveness of screening or that
the potential benefits outweigh the risks [2]. Public health
agencies are recommending that physicians and patients
should reach a decision about screening collaboratively
via shared decision making [2-5]. This allows patients to
be informed about the benefits and risks of PC screening,
treatment and to include their own values and preferen-
ces in the process.
Primary care physicians play an important role in can-
cer care and screening but relatively little is known about
their PC knowledge, practice and training [6]. Physician
surveys revealed that different doctors have different be-
liefs and practices about PC screening and counseling
[7-9]. Chan and colleagues found that physicians do not
agree on the facts that men need to know and to make an
informed decision about PC screening [8]. In Saudi Ara-
bia, physicians’ practice and its determinants towards PC
screening have never been examined. Understanding these
perceptions will help identify continuous medical educa-
tion (CME) training needs of physicians. This will guide
tailoring an effective CME program about PC counseling
and decision making that could be integrated into pri-
mary care prevention. Therefore, this study aimed to as-
sess primary care physicians’ practice skills and their atti-
tude towards prostate cancer counseling, screening and
referral.
2. SUBJECTS AND METHODS
2.1. Study Design and Setting
A cross-sectional descriptive study was conducted in
the city of Riyadh (the capital of Saudi Arabia) during
the period May through October 2009. All Primary health
care physicians were invited to participate in the study.
The survey questionnaire was sent to Physicians in dif-
ferent institutions. University hospitals, Army hospitals,
Ministry of health hospitals and King Faisal specialized
hospital representing different health sectors in the city.
The study was approved by the research ethics commit-
tee at the authors’ hospital and at each of the partici-
pants’ hospitals.
2.2. Study Tools
A self-administered structured questionnaire was de-
veloped. It included the following information: Personal
data, characteristics of prostate cancer counseling and
screening (PCC&S). Eight questions were used to assess

D. M. Rabah et al. / HEALTH 2 (2010) 1312-1315
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1313
time devoted in PCC&S, percentage of patients suspect-
ed and referral for PSA reasons for PCC&S with asymp-
tomatic patients, issues discussed during PC counseling,
rating their skills in PCC&S, resourced used to get in-
formation about PC. Physicians’ knowledge about PC:
This scale comprised 29 questions that examined know-
ledge regarding different facts about the prostate. For ea-
ch question the correct answer was given a score of one
and incorrect answer was given zero. Physicians’ atti-
tudes towards PCC&S: A scale of nine items was de-
signed as three points Likert scale (agree, neutral, dis-
agree) to ascertain physicians’ attitude toward accuracy
and evidence supporting screening as well as their role
in screening. For each item, the response was scored
from 1-3 with higher score for more favorable attitude
toward PCC&S.
2.3. Statistical Analysis
Data was processed and analyzed by SPSS, version 17.
AVOVA test and t test were used as tests of significance.
The level of significance used was at p value < 0.05. For
testing internal consistency of different scales, Chron-
bach α reliability test was used, 0.65 for attitude scale
and 0.75 for knowledge scale. Logistic regression was
used to explore the effect of different factors predicting
the physicians’ practice towards prostate cancer counsel-
ing and screening, the dependent variable was physicians’
referral versus non referral.
3. RESULTS
Out of the 405 primary health care physicians surveyed,
204 returned the questionnaire, giving a response rate
50.3%. Fifty six questionnaires were excluded due to
incomplete answers, giving a final total of 148 responses.
The mean age of the participants was 41.35 ± 8.83 years
(range, 25-60 years). Only 21(14.2%) were non Arabic
speakers. The mean years of experiences were 3.61 ± 1.37
years.
The present study revealed that nearly half of the re-
spondents (54.7%) were counseling, screening and some-
times referring PC patients , the main reasons were the
age of the patient; being above 50 (35.8%), family his-
tory (31.8%) and upon patient’s request (23.3%).
In general, in terms of percentage, the mean correct
knowledge score was 54.3% (Table 1). Regarding dif-
ferent knowledge items, the majority of the respondents
knew that age above 50 years, family history, black race,
and tobacco smoking are risk factors of PC. The least
known risk factors were high fat diet and obesity (50%)
and multiple sex partners (20.9%). The most frequent
medical problems that make PHC physicians recom-
mend PC screening were weak urinary stream (81.1%),
Table 1. Distribution of the PHC physicians by their correct
knowledge about PC and screening.
Knowledge items No (148)%
Risk factors:
‐ Age below 50 year (F)
‐ Family history
‐ White race (F)
‐ Tobacco smoking
‐ High fatty diet and obesity
‐ Number of man’s sexual partners
128
121
111
107
74
31
86.5
81.8
75.0
72.3
50.0
20.9
Medical problems to recommend PC screening :
‐ Weak urinary stream
‐ Hematuria
‐ Blood in semen
‐ Family history
‐ Starting & stopping while urinating
‐ Frequent pain or stiffness in the lower back
‐ Increased urinary urgency
‐ Increased urinary frequency
‐ Nocturia
‐ Painful ejaculation
‐ Erectile dysfunction
120
106
98
97
89
88
86
75
61
59
46
81.1
71.6
66.2
65.5
60.1
59.5
58.1
50.7
41.2
39.9
31.1
Function of the prostate 88 59.5
Normal value of PSA for a man under 60 year 102 68.9
PC routine screening:
‐ PSA
‐ DRE
‐ Transrectal ultrasound
117
103
44
79.1
69.6
29.7
Can false positive PSA test occur 129 87.2
Nutrients recommended for prevention of PC;
‐ Selenium
‐ Vitamin E
‐ Green Tea
‐ Low fat diet
‐ vitamin D
‐ Beta carotenes
23
48
34
88
8
17
33
15.5
32.4
22.9
59.5
5.4
11.5
22.3
and hematuria (71.6%), meanwhile the least mentioned
were painful ejaculation (39.9%) and erectile dysfunc-
tion (31.1%). Only 59.5% and 68.9% knew correctly the
function of prostate and normal value of PSA for a man
under 60 year respectively. Also, 79.1% and 68.9% knew
that PSA and DRE are used for routine PC screening.
Uncertainty about nutritional knowledge was evident
among PHC physicians.
As shown in Table 2, the mean total attitude score
was 19.25 which was slightly higher than midpoint (18)
of the actual range of that score (9-27). For different
attitudinal statements, “It is more appropriate for spe-
cialists to screen for PC” had got the highest favorable
mean score (2.64) which delineates that the majority of
PHC physician accepting PC&S to be their role. Also C

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Table 2. PHC physicians’ attitudes towards PCC&S.
SD Mean (Range 1-3)Agree % Attitude statements
.65 2.62 71.6 1) Early detection through screening can improve survival for men with PC
.77 2.22 43.2 2) PCC&S should be routinely used on all men beginning at age 50
.67 1.85 16.2 3) DRE is an accurate screening test for prostate cancer
.75 1.80 20.3
4) There is evidence to support using DRE for PC screening on asymptomatic men with no risk
factors
.64 2.51 8.1 5) DRE is unaccepted from Saudi men , so physicians should avoid it
.79 1.91 27.0 6) PSA is an accurate screening test for prostate cancer
.76 1.66 17.6
7) There is enough evidence to support using PSA for PC screening on asymptomatic men with
no risk factors
.67 2.64 10.8 8) It is more appropriate for specialists to screen for PC
.79 2.04 29.7 9) I think that PSA testing leads to excess subsequent unnecessary investigations
2.97 19.25 Total attitude score (actual range 9-27)
the majority had favorable attitudes towards “Early de-
tection through screening can improve survival for men
with PC” (x̄ = 2.62). The least favorable attitude scores
were for the reliability and accuracy of DRE and PSA
testing.
The results of the final model of logistic regression is
presented in Table 3, it appears that total knowledge
score and total attitude score were the most significant
variables that could predict physicians’ practicing to-
wards PCC & S, while self efficacy had border line sig-
nificance.
4. DISCUSSION
It was found that physicians who were influenced by
scientific evidence were more likely to practice informed
decision making with their patients particularly primary
health care physicians who are more likely to believe
that men need to know facts about uncertainties of PSA
testing to make such decision [10].
Nearly half of the physicians (54.7%) in the present
study were practicing PCC & S, their mean correct
knowledge score was 54.3% and their attitude towards
PCC & S in the current study was not strong. An inter-
esting finding which should be addressed: that despite
the majority of respondents hold a strong belief that PCC
& S is mainly their role, their practice towards in coun-
seling, screening and/or referral was poor. The results of
Curran et al. suggested that the vast majority of primary
care physicians in Newfoundland and Labrador screen
asymptomatic male patients for prostate cancer, and they
had very positive attitudes towards prostate screening,
where most of them agreed that prostate screening
should be routinely performed on all men beginning at
age 50 and that early detection with screening can im-
Table 3. Determinants of physicians’ practice towards prostate
cancer counseling and screening.
95.0% C.I.
Variables B S.E.
Odds
Ratio Lower Upper
Total knowledge
score -0.138.048 .87 0.79 0.95
Total attitude
score -0.183.071 .83 0.72 0.95
Total self-efficacy
score -0.011.009 .98 0.97 1.002
Years of
experience 0.07 .144 .93 0.70 1.25
Previous CME in
PC 0.69 .67 1.99 0.53 7.45
prove survival for men with prostate cancer [11]. On the
other hand, Pendelton J. and his colleagues found that
the mean correct score on the knowledge questions was
59%, only 52% of physicians in that study reported rou-
tine screening in minority men and that physicians’
knowledge is not an important predictor of their screen-
ing behavior [12].
Our results implied that knowledge and attitude were
the most important significant predictors of physicians’
practice of PCC & S, which came in accordance with
previous researchers revealed that physician knowledge
of specific disease process greatly influenced screening
behavior [3-15] and a positive attitude towards screening
can be a significant predictor of ordering or performing
such screening tests [13,16,17].
The results of the present study support the fact that
physicians’ practice towards a screening procedures or
early detection of diseases should rely on a good back-
ground of information which in turn enhances their self
efficacy and develops a good and positive attitude to-
wards their practice skills. Further research should be

D. M. Rabah et al. / HEALTH 2 (2010) 1312-1315
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
1315
Openly accessible at
undertaken to recognize how to assist men make informed
decisions about prostate cancer testing.
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