Innovative JournalJournal of Medical Research and Health Sciences2589-90312589-9023https://doi.org/10.15520/jmrhs.v4i7.378Original ArticleLevel of Awareness of Colorectal Cancer Among Patients Attending Primary Care in Single Center: A Cross-Sectional Study in Saudi ArabiaAwareness of Colorectal Ca Primary Care PatientsAlhemiddiAfnan Nasser1AlharbiAbdulhalim2Family medicine resident, Security forces hospital, Riyadh, Saudi Arabia Family medicine consultant, security forces hospital, Riyadh, Saudi Arabia 2072021471350115202110720213052021The Authors. Published by Medical Editor and Educational Research Publishers Ltd. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/)2021Abstract
BACKGROUND: Globally, colorectal cancer (CRC) is the third most common cancer diagnosed and the second leading cause of cancer deaths
OBJECTIVES: this study aims to evaluate the knowledge level of colorectal cancer risk factors, symptoms, and screening modalities among patients attending Primary Care Center to identify the population that might benefit from targeted future health education programs
METHOD: This was a cross-sectional survey study that has been conducted at the primary care centers at Security Forces Hospital (SFH), Riyadh, Saudi Arabia. The study participants were patients attending the primary care center at Security Forces Hospital during the study period from January 1st, 2020 To April 30th,2020
RESULTS: A total of 384 patients participated in the study, 57.6% of them were females, the highest percentage (40.6%) were in the age group of 30-39 years old, and 60.9% were married. Almost half (49.2%) of the participants reported having educational level as college and above. A 49.1% of the respondents correctly know what is the colon, Only 12.8% correctly know that screening for colorectal cancer is at the age of 50, 83.5% of the respondents know that family history of CRC is a risk factor, 56% scored colonoscopy as the screening tool, while only 6.5% scored the microscopic stool examination. the mean (±SD) of the overall knowledge score was 4.63(±2.26) out of 10, The results revealed no significant differences (P>0.05) in the total knowledge score by gender, age, or marital status, being higher among females, those aged 50-59 years, and single participants. In contrast, lower educational level subjects are almost four folds at increased risk of poor knowledge about CRC, with OR=3.84, and a P-value of <0.001.
CONCLUSION: this study indicate gaps in the awareness of CRC Among Patients Attending Primary Care Canters in Riyadh, Saudi Arabia. Increasing patient knowledge may promote lifestyle changes and appropriate screening behavior that could reduce individual risk of CRC.
Keywordscolorectal cancer (CRC)risk factorssymptomsscreening modalitiesprimary carecross-sectionalIntroduction:
Globally, colorectal cancer (CRC) is the third most common cancer diagnosed and the second leading cause of cancer deaths 1. CRC, also known as colorectal adenocarcinoma, is a type of cancer that develops in the glandular, epithelial cells of the large intestine. Cancer develops when specific epithelial cells acquire a succession of genetic or epigenetic alterations that give them a selective advantage 2. With abnormally heightened replication and survival, these hyper-proliferative cells give rise to a benign adenoma, which may then evolve into carcinoma and metastasize over decades 3. CRC arises from the epithelium (lining) of the colon or rectum, and as a result of tumor growth, the intestine starts bleeding and gets obstructed.
Globally, the regional incidence of CRC varies by a factor of ten. Australia and New Zealand, Europe, and North America have the greatest incidence rates, whereas Africa and South-Central Asia have the lowest 4. These geographic differences appear to be due to differences in dietary and environmental exposures imposed on a background of genetically determined susceptibility. During 2018, there were nearly 1.8 million new cases of CRC and 860 000 deaths. The global burden of CRC is expected to rise by 60% by 2030, resulting in more than 2.2 million new cases and 1.1 million deaths 5. Furthermore, CRC incidence and mortality have increased rapidly in several middle- to high-income countries in Asia, Eastern Europe, and South America 6. In Saudi Arabia, CRC is the second most common type of cancer in Saudi Arabia, according to the Saudi Cancer Registry (SCR) in 2014. Furthermore, it was the most common cancer among Saudi males and the third most common cancer among Saudi females. Although Saudi Arabia has a low incidence rate of colorectal cancer in comparison to other countries, the incidence rate and cancer-related deaths have increased significantly over the last ten years 7, 8.
For risk factors, both genetic and environmental factors play an important part in the etiology of colorectal cancer. Elderly people above 50 years, male gender, People with first-degree relatives who were diagnosed with CRC, and high red meat diet, and low fiber intake diet 9. This is in addition to smoking, high alcohol consumption, certain medication, diabetes, being overweight, and an inactive lifestyle 9.
Colorectal cancer patients may be symptomatic for many months before presentation. They may experience multiple symptoms including a change in bowel habitus such as diarrhea, constipation that lasts for more than a few days, rectal bleeding, weakness and fatigue, unintended weight loss, cramping or abdominal pain, and the desire to have a bowel movement when the bowel is empty 10, 11. A diagnosis of colorectal cancer either results from an assessment of a patient presenting with symptoms or as a result of screening. With the widespread introduction of population screening for colorectal cancer, many individuals are diagnosed at a pre-clinical stage. In symptomatic patients, colonoscopy is the preferred method of investigation, but other endoscopic methods are also available 9. For population screening, a range of other methods can be used for primary assessment, followed by colonoscopy in case of a positive test 9. Colonoscopy is the gold standard for CRC diagnosis; it has high diagnostic accuracy and can assess tumor location. Notably, the technique allows for simultaneous biopsy sampling and, as a result, histological confirmation of the diagnosis as well as material for molecular profiling. Colonoscopy is also the only screening technique that can be used for both diagnostic and therapeutic purposes 9.
Globally, many research studies have evaluated the public knowledge of CRC. A study from Chinese, Korean, and Vietnamese Americans aged 50-75 years old a good knowledge score was reported 12. In the Kingdom of Bahrain, a study was conducted and showed that the most frequently chosen risk factor for CRC was family history (38%) and smoking (28%). In addition, changes in bowel movement was the most recognized symptom (46%) and lower abdominal pain came next (44%),and Female participant were having more knowledge regarding colorectal cancer in comparison to male participants 13. In comparison, a study was conducted in Kuwait showed that the genetic predisposition and family history were the most frequently chosen risk factors by, and the most commonly selected symptoms were bloody stool, abdominal pain, and intestinal obstruction. Also, MRI was the most frequently recognized screening test by respondents and followed by CT scan. However, most of the participants have no idea about the screening modalities of colorectal cancer 14. In the United Arab Emirates, a study showed that most of the participants have no knowledge regarding colorectal cancer risk factors (59.4%), and its symptoms (74.8%) or screening modalities (53.5%) 15. locally, a study was conducted in Asir region revealed that a limited percentage of participants know the symptoms, risks factors, and screening tests of colorectal cancer 16. Another study was conducted in Riyadh city showed that most of the participants were having inadequate knowledge about CRC screening methods 17.
We conducted this study to evaluate the knowledge level of colorectal cancer including risk factors, symptoms, and screening modalities among patients attending Primary Care Center to identify the population that might benefit from targeted future health education programs.
Methods:
This was a cross-sectional survey study that has been conducted at the primary care centers at Security Forces Hospital (SFH), Riyadh, Saudi Arabia. The study participants were patients attending the primary care center at Security Forces Hospital during the study period from …. To …….The study included patients from both genders, aged 18 – 80 years who agreed to participate, while those in other age groups, or who have a prior history of colorectal cancer or inflammatory bowel disease and those who refused to participate were excluded.
Data was collected using a validated and reliable self-administered questionnaire that was constructed to evaluate the level of awareness of colorectal cancer. The questionnaire consists of 10 multiple choice questions related to the risk factors, symptoms, and screening modalities.
The sample size was calculated using the Raosoft calculator. Assuming the target population to be studied is more than 20,000 subjects using a confidence level of 95%, and a margin of error of 5% a minimum sample size required for this study is 377. A Convenience sampling technique was used in this study, which is a type of non-probability sampling technique. A hard copy of the questionnaire was distributed among patients in waiting areas in the Primary Care Center at Security Forces Hospital, Riyadh, Saudi Arabia.
The study has been conducted after taking ethical approval from the Research Ethics Committee at Security Forces Hospital, Riyadh, Saudi Arabia. Confidentiality was considered by keeping participants’ data secured and private. A consent form was taken after explaining the aims and objectives of the study to the participants without any ambiguity, and they were informed that they have the right to withdraw at any time.
Statistical analysis:
Data were analyzed by using Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. The t-test and one-way ANOVA were used for continuous variables. Univariate and multivariate logistic regression was used to assess the associated factors with the low level of knowledge. A p-value <0.05 was considered statistically significant
Results
The baseline characteristics of the study participants are shown in table (1). A total of 384 patients attending primary care centers at SFH participated in the current study, more than half of them were females at 57.6%, the highest percentage (40.6%) were in the age group of 30-39 years old, and 60.9% were married. Almost half (49.2%) of the participants reported having educational level as college and above.
Table1 : Characteristics of the participants
Participants' answers for the questions of knowledge of colorectal cancer risk factors and symptoms and the percentage of correct answers are shown in tables (2 and 3). A percentage of 49.1% of the respondents correctly know what is the colon, while only 38% know that the rectum is the last part of the large intestine. Participants showed poor knowledge regarding the colon function as only 21.6% and 11.2% know that it is responsible for waste storage and water reabsorptions, respectively. The highest percentage (43.8%) of the participated patients knows that the incidence of colorectal cancer is average. Only 12.8% correctly know that screening for colorectal cancer is at the age of 50, while the majority (75%) think that it should be at the onset of symptoms. Participants showed a good knowledge level in regards to colorectal cancer symptoms, where 77.9%, 73.7%, and 58.1% identified blood in stool, nausea, and vomiting, and change in bowel habits as symptoms of CRC, respectively. For CRC risk factors, 83.5% of the respondents know that family history of CRC is a risk factor, 65.9% reported smoking and 50.8% reported inflammatory bowel disease as risk factors. While the majority (>80%) thought that fatty food and colon polyps are risk factors for CRC. For CRC screening modalities, 56% scored colonoscopy as the one, while only a very low percentage (6.5%) know that microscopic stool examination is one of the used modalities. CRC is a curable disease and this was knowledgeable by 63.3% of the participants. There is no relation between irritable bowel syndrome and CRC, and 33.6% of the participated patients know this, while 24.2% thought that they are correlated.
Table2 : Answers for the questions of knowledge of colorectal cancer risk factors and symptoms
Table3 : Percentages of correct answers of knowledge of colorectal cancer risk factors and symptoms
Table (4) shows the mean and standard deviation of the total score of knowledge of colorectal cancer risk factors and symptoms by characteristics of the participants. the mean (±SD) of the overall knowledge score was 4.63(±2.26) out of 10, indicating poor knowledge. The results revealed no significant differences (P>0.05) in the total knowledge score by gender, age, or marital status, being higher among females, those aged 50-59 years, and single participants. In contrast, the knowledge score differed significantly by the educational level, and it was the highest among those who have college and above at 5.10(±2.08).
Table4 : Mean and standard deviation of the total score of knowledge of colorectal cancer risk factors and symptoms by characteristics of the participants
* Significant p value
** out of 10
Likert scale was used with total score of 10 ( 0 = false answer , 1 = correct answer )
Univariate logistic regression for the associated factors with a low level of knowledge of colorectal cancer showed that low educational level subjects are almost four folds at increased risk of poor knowledge about CRC, with OR=3.84, and a P-value of <0.001, as shown in table (5).
Table5 : Univariate logistic regression for the associated factors with low level of knowledge of colorectal cancer
* Significant p value
** used as a reference
Discussion
Patient awareness of CRC has not been well described in Saudi Arabia. Understanding and recognizing public awareness regarding CRC may provide valuable information to incorporate the policy decision for prevention, early diagnosis, and improvement of survival for CRC. Therefore, this study aimed to assess and identify the level of knowledge and awareness of CRC with regards to its risk factors, symptoms, and screening/imaging procedures. The results of the current study revealed an overall poor knowledge about CRC among patients attending primary care centers in Riyadh, Saudi Arabia
The current study finding of poor knowledge about CRC is in line with previous similar local, national, and international studies 18, 19, 20, 21. In contrast, a recently published Chinese study revealed a good knowledge of CRC and its screening among people aged 50–75 years 22
Environmental and genetic factors can increase the likelihood of developing CRC 23. Although inherited susceptibility results in the most striking increases in risk, the majority of CRCs are sporadic rather than familial 23. In Bahrain, a previous study found that changes in bowel habits (46%) and family history (38%) were the most often reported symptoms of CRC 19, in the current study, blood in the stool (77.9%), and nausea and vomiting (73.7%) were the ones.
For CRC risk factors knowledge, a previous study from Kuwait showed that the most frequent risk factor that was chosen by the participants was the genetic factors and family history (73.5%) 24, while in our case, family history of CRC was the most frequently chosen risk factor at 83.6%. People with first-degree relatives who were diagnosed with CRC have a greater risk of developing the disease by 2 to 3 times, compared to individuals with no family history 24. In general, elderly people above 50 years have a higher chance of developing CRC 25, however, only 12.8% of the res[pendent patients in the current study know that they should screen for CRC at the age of 50. However, CRC incidence is rising in persons under age 50, and a thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended [25].
It was noticed that almost half of the participants’ knowledge know colonoscopy as a screening modality for CRC. Advantages/benefits of the entire procedure of colonoscopy on detecting CRC at an early stage should exist. In addition, knowledge of various diagnostic procedures should be reinforced during public campaigns, and educational programs are needed to raise public awareness on the imaging modalities focusing on the advantages and disadvantages of each.
A lower educational level has been found to have significant negative associations with knowledge and practice towards CRC screening 22. Similar findings were reported in the current study. Subjects who attained lower education had poorer knowledge related to CRC and CRC screening 22. Understandably, those who have a lower educational level may need more support to understand the content of CRC screening programs. Additionally, those people are usually situated at a lower socioeconomic level and have more difficulties in obtaining adequate knowledge through new media. When low educated subjects do not receive adequate information, their intention or motivation to participate in the screening programs will be reduced 26, 27.
CRC is a disease that everyone tries to avoid. As a result, increasing public awareness in the community is critical. This could be accomplished by exposing the public to more educational resources, such as TV show posters, information leaflets distributed in public places, and the continuation of public seminars. According to the guidelines, general practitioners should routinely monitor patients' BMIs, assess risky behavior, promote healthy eating, drinking, and physical activity, and recommend appropriate CRC screening 28.
Conclusion
Our results indicate gaps in the awareness of CRC Among Patients Attending Primary Care Canters in Riyadh, Saudi Arabia. Increasing patient knowledge may promote lifestyle changes and appropriate screening behavior that could reduce individual risk of CRC.
Financial support and sponsorship: Nothing to be declared
Acknowledgement: Authors acknowledge all primary authors of the included studies for their assistance and academic support.
Conflicts of interest: There are no conflicts of interest.
This manuscript has been read and approved by all the authors, the requirements for authorship have been met, and each author believes that the manuscript represents honest work.
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