Public awareness of risk factors of gastric cancer and attitude toward disease screening in Saudi Arabia

Introduction

Although incidence of gastric cancer in falling worldwide, it is the second leading cause of cancer-related mortality and the fourth most common cancer globally. Gastric cancer has geographical differences where significantly more cases of gastric cancer were reported in less developed countries than in more developed countries[1] . Comparing nations, the highest incidence rates are observed in East Asia, East Europe, and South America, while the lowest rates are observed in North America and most parts of Africa. Gender differences were Also reported with a rate of 2 to 3 folds higher in men[2] . Gastric cancer patients commonly present with vague symptoms such as dyspepsia in early stages. In advanced stages, patients might present with abdominal pain, weight loss, anorexia, or symptoms related to the site of tumor[3] . Diagnosis of gastric cancer remains a challenge as it is detected most of the time at late stages. Various diagnostic tools exist, but endoscopy and biopsy are needed to make diagnosis[4] .

In spite of high mortality and morbidity of gastric cancer, no well-established screening program has been implemented worldwide except for countries where incidence of gastric cancer is high such as South Korea[5] . Different screening programs were implemented in the past in countries with high incidence of gastric cancer. Upper gastrointestinal series, gastroscopy, Helicobacter pylori antibody and serum pepsinogen screening were used in Japan[6] . A large Japanese case-control study suggest 30% reduction in gastric cancer mortality by endoscopic screening compared with no screening within 36 months before the date of diagnosis of gastric cancer[7] . A recent meta-analysis found that an endoscopic screening for gastric cancer in Asian populations showed 40% reduction in mortality[8] .

Known risk factors of gastric cancer are previous Helicobacter pylori infection, old age, male gender, smoking, alcohol drinking, obesity, family history, and dietary habits. Dietary habits known to be a risk for gastric cancer are eating processed meat, salty or smoked food, and lack or inadequate intake of vegetables and fruit[9] . Dietary habits were believed to be responsible for the geographical variation of incidence of gastric cancer[10] . Public knowledge of warning signs and risk factors of gastric cancer hasn’t been well-studied worldwide. A South Korean population-based study testing the public awareness of gastric cancer suggested that stress is believed to be the strongest factor to develop gastric cancer followed by chronic gastritis, and gastric ulcer. 60.4% Thought cancer can be prevented by lifestyle modifications such as avoidance of salty food and smoking[5] . Other study in prevalent area or gastric cancer in northern of Iran suggested that 74% of people believe that anemia is a warning sign of gastric cancer, and 91% believe that smoking is the most powerful risk factor, and cessation of smoking is the best way to prevent the cancer[11] . In addition, a recent study conducted in China to assess people attitude toward screening, 47% showed low level of knowledge about warning signs and risk factors of gastric cancer, and 63% think that the reason for not undergoing a regular screening is lack of symptoms[12] .

The incidence of gastric cancer has been studied in Saudi Arabia, but no study has been conducted to assess people knowledge of gastric cancer and its risk factors. Although gastric cancer in Saudi Arabia incidence is falling, a large retrospective study in Riyadh suggested gastric cancer to be the most frequent gastrointestinal cancer[13] . In 2013, The Saudi Arabia Cancer Incidence Report showed that gastric cancer to rank the 9th cancer among men and the 12th in women. It accounts for 2.7% of all adult cancers in Saudi Arabia, and the median age at diagnosis was 65[14] .

High morbidity and mortality of gastric cancer mandates education of Saudi population, and reduction of mortality in high-risk population was significant. Studies regarding knowledge about gastric cancer are lacking in Saudi population. This study might serve as basis for future practice and a step toward assessing quantitively people perception of preventable risk factors and warning signs of gastric cancer and attitude toward screening and early detection.

Methods

A cross-sectional study was conducted in September 2019 using pretested questionnaire through social media applications. The questionnaire was distributed along with structured informed consent by King Abdullah International Medical Research Centre. The calculated sample size is 1067 with 3% margin of error and 95% confidence level. The inclusion criteria was all Saudi males and females over the age of 18. The exclusion criteria was age less than 18, not living in Saudi Arabia, and non-Saudi participants.

The questionnaire used includes questions on the following issues:

1. Sociodemographic data.

1. Perception of the self-risk of gastric cancer

1. Awareness of the attributable and preventable extent of each risk factor for gastric cancer

1. Genetic factors of gastric cancer development

1. Factors preventable by lifestyle modification

1. Value of early detection and attitudes toward regular screening

Relationship between respondents’ self-risk of gastric cancer and baseline characteristics were observed by Chi-Squared test. The Significance was set at p<0.05. The analysis was performed using the Statistical Package for Social Science (SPSS), version 24.0 (IBM, Armonk, NY, USA). The IRB was sought and approved by King Abdullah International Medical Research Centre. IRBC/1567/19

Results

Total of 1410 respondents were included in this study and among them 858 (60.9%) were females. All respondents were adults and most of them were aged between 19 years to 29 years, 843 (59.8%). Majority of respondents had high educational level (college or above), 1093 (77.5%), reported having a good health status, 1236 (87.7%), non-smoker, 1226 (87.0%), and non-alcoholic, 1367 (97.0%) (Table 1). According to respondents’ perception of self-risk of gastric cancer, 693 (49.1%) had very low risk, 574 (40.7%) had low risk, 137 (9.7%) had average risk, and the remaining six respondents (0.4%) had high risk (Chart 1).

Table 1: Baseline characteristics of the respondents (n = 1410)
Characteristics	Attributes	N	%
Gender	MaleFemale	552858	39.160.9
Age in years	19-29 30-39 40-49 50-59 60 or more	84319719415719	59.814.013.811.11.3
Level of education	Elementary school Intermediate school High school Bachelor Other	420225109368	0.31.416.077.54.8
Health status	Good Intermediate Bad	12361704	87.712.10.3
Smoking	YesNo	1841226	13.087.0
Alcoholism	YesNo	431367	3.097.0
Consumption of salty food	Always Sometimes Rarely Never	4677741618	33.154.911.40.6
Consumption of spicy food	Always Sometimes Rarely Never	232696354128	16.549.425.19.1

Chart 1: Distribution of all respondents by their perception of self-risk of gastric cancer (n = 1410)

Study participants were aware of ‘chronic infection’ as gastric cancer most powerful risk factor, 764 (54.2%), followed by ‘alcoholism’, 725 (51.4%), smoking, 707 (50.1%), and Helicobacter pylori infection, 655 (46.5%). The factors that the respondents were the least aware of were ‘vegetables or fruits’, 11 (0.8%) followed by, ‘gender’, 52 (3.7%), and ‘previous gastrectomy’, 140 (9.9%). When asked about the gastric cancer prevention if a certain factor was removed would lead to reduction of incidence of gastric cancer, the highest number of respondents recognized ‘smoking’, 722 (51.2%), then ‘alcoholism’, 623 (44.2%), and ‘H. pylori infection’, 589 (41.8%) (Chart 2, 3).

Chart 2: Distribution of all respondents by awareness about the factors responsible for gastric cancer, N (%) (n =1410)

Chart 3: Distribution of all respondents by their thought of gastric cancer prevention when a certain risk factor is totally removed, N (%) (n =1410)

About 30% of the respondents thought gastric cancer is genetically predetermined, 50% thought it can be prevented by lifestyle modification, and 50% thought gastric cancer could be fully curable (Table 2). Regarding the usefulness of regular gastric cancer screening, 1011 (71.7%) answered ‘very useful’ but only 30 (2.1%) undergo regular screening for gastric cancer. The predominant reason for not undergoing regular gastric cancer screening was ‘no symptoms’, answered by 620 (44.0%) respondents. Respondents’ no idea about gastric cancer screening was the second biggest cause (27.0%) for not regularly undergoing gastric cancer screening.

Table 2: Distribution of all respondents by their knowledge of genetic predisposition, lifestyle modification, and curability of gastric cancer (n = 1410)
	What % of gastric cancer do you think is genetically predetermined?	What % of gastric cancer do you think is preventable by modification of lifestyle?	What % of gastric cancer do you think is curable?
Mean	40.0525	60.4915	49.3582
Std. Error of Mean	5.75506	7.45304	0.79989
Median	30.0000	50.0000	50.0000
Std. Deviation	216.10240	279.86128	30.03589

Respondents’ age, (p <.001), health status (p <.001), smoking habit (p <.001), drinking habit (p .008), consumption of salty food (p <.001), and consumption of spicy food (p <.001) were statistically significantly characteristics associated with their ‘self-risk’ of gastric cancer. However, gender, and level of education were not significantly associated with ‘self-risk’ of gastric cancer (p values > .050) (Table 4).

Table 4: Relationship between respondents’ self-risk of gastric cancer and baseline characteristics.
Characteristics	Self-risk	p-value
Very low %	Low %	Average %	High %
GenderMaleFemale	38.761.3	39.061.0	41.658.4	50.050.0	.872
Age in years19-29 30-39 40-49 50-59 60 or more	51.516.716.214.01.6	68.612.011.37.10.9	65.78.810.913.11.5	33.30.0033.316.716.7	<.001
Level of educationElementary school Intermediate school High school Bachelor Other	0.41.615.676.55.9	0.01.416.678.63.5	0.70.016.178.84.4	0.016.70.066.716.7	.088
Health statusGood Intermediate Bad	92.47.40.3	84.515.50.0	79.619.70.7	33.350.016.7	<.001
SmokingYesNo	8.491.6	17.882.2	16.183.9	33.366.7	<.001
AlcoholismYesNo	1.698.4	4.295.8	5.194.9	16.783.3	.008
Consumption of salty foodAlways Sometimes Rarely Never	29.154.715.60.6	34.857.17.30.7	45.347.47.30.0	50.033.316.70.0	<.001
Consumption of spicy foodAlways Sometimes Rarely Never	14.447.026.312.3	16.453.723.96.1	24.844.524.85.8	66.716.716.70.0	<.001

Discussion

Gastric cancer incidence is declining worldwide, but it remains the second leading cause of cancer-related mortality. Gastric cancer carries a very wide geographical variety where is it more common in Japan, South Korea, and China than other parts of the world[1] . Gastric cancer burden in Saudi Arabia is less where it ranks the 9th cancer among men and the 12th in women. It accounts for 2.7% of all adult cancers in Saudi Arabia[14] . The level of public knowledge about risk factors of gastric cancer has not been studied yet in Saudi Arabia.

Public awareness of gastric cancer has been studied previously in South Korea, Iran, and China[5, 11, 12] . Those three studies showed general lack of knowledge about the risk factors of gastric cancer. In our study, 54.2% of respondents chose the chronic infection as risk factor followed by alcohol drinking 51.4% and smoking 50.1%. These finding show gaps of knowledge about the role of diet, previous stomach surgery and genetics which are well-established risk factors as well[9] . Also, 49.1% and 40% of the respondents think their risk of developing gastric cancer is very low and low respectively. Surprisingly level of education was not associated with self-perception of risk of gastric cancer

There is no nation-wide implemented regular screening program in Saudi Arabia. People who had undergone a gastroscopic screening were selective cases in which they have some symptoms or family history. Only 2.1% of respondents had undergone screening. Respondents main reason not to go for screening was having no symptoms 44% and not having an idea about screening 27%. The incidence of gastric cancer in Saudi Arabia is declining despite poor prognosis, but the burden of gastric cancer is less compared to the burden of other cancers which make the cost-effectiveness of regular screening questionable. That makes the need for spreading knowledge about risk factors and warning symptoms is necessary for the people to seek help when they have symptoms.

The main strength of the study is number of respondents. The response rate was 100%, and 1410 have participated in the questionnaire. Which is attributed to the short survey and the questionnaire being distributed in most popular social media means in Saudi Arabia such as Twitter and WhatsApp. The study has some limitations as well. First, most of questions were answered subjectively. There were no specific definitions defining specific terms such as health status and salty, spicy, and charred food. Second, inclusion criteria involved all Saudis aged over the age of 18 and no exclusion of patients of personal history of cancer. Third, most of the respondents were aged between 19-29 and of high educational level which might explain most of participants are having a good health and low self-perception of the cancer.

Conclusion

The study shows low level of knowledge of gastric cancer risk factors in Saudi Arabia, but it indicates positive attitude toward screening with only 30 respondents undergoing regular screening. More health awareness campaigns should be considered to improve knowledge about gastric cancer risk factors in Saudi population.

References

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Appendix