Knowledge of Gastric Cancer Risk Factors, Warning Symptoms, and Screening Among the General Population in Makkah, Saudi Arabia

1. Introduction

As stated by the last Global Cancer Statistics (GLOBOCAN 2018), incidence and mortality of cancer are highly increasing worldwide, in which there were 18.1 million new cancer cases and 9.6 million cancer deaths in 2018 1. Gastric Cancer (GC) is one of the most dangerous cancers worldwide that is responsible for over 1,000,000 new cases in 2018 and approximately 783,000 deaths, making it the third leading cause of cancer death, and the fifth most prevalent cancer, after lung, breast, prostate, and colorectal cancers 1. These numbers showed a significant difference compared to the very first estimates in 1975 2. There is a variation in the Incidence of GC from one country to another. The last estimates on GLOBOCAN 2018 released by the International Agency for Research on Cancer (IARC) published in 2019, reported 477 new cases and 392 deaths of GC in the Kingdom of Saudi Arabia (KSA) in 2018, ranked the 16th most prevalent cancer for both sexes 3, which reflects an increase in the incidence over the last decade.

It is well established that a high intake of a salty diet, lack of fresh fruits and vegetable intake, alcohol consumptions, and active use of tobacco are associated with increasing the chance of gastric cancer 4,5. The main risk factor is Helicobacter pylori (H. pylori) infection 4-7. This bacterium is responsible for about nearly 90% of new cases of non-cardia gastric cancer 6,7. Moreover, genetic, and epigenetic factors are contributing to the progression of GC 8.

A study done on the matter found that those aware of the association between H. Pylori infection and gastric cancer tend to undergo screening and receive treatment for H. Pylori infection more than those who are unaware 9. The most common symptoms of GC include upper abdominal pain, recent onset of indigestion, and weight loss. These symptoms may indicate other medical conditions, wherefore, People with these symptoms need to seek medical attention as soon as possible 10. Awareness of these symptoms may lead to early diagnosis 11; additionally, early stages of GC have a significantly better prognosis than advanced GC 12,13. Hitherto, there is insufficient evidence to recommend endoscopic screening 14, currently, the treatment of GC involves a combination of surgery, chemotherapy, and radiotherapy 15.

In two previous studies done in KSA, the knowledge and awareness of cancer among the participators were low and less than required 16,17. No further studies have been done on the population of Makkah city, KSA. Hence, updated studies that assess GC awareness are necessary as a basis for future practices. Accordingly, this study aims to assess the level of knowledge of risk factors, warning symptoms, and the screening attitude regarding GC among the general population in Makkah, KSA. Besides, to explore socio-demographic factors associated with the knowledge of GC.

2. Methods

2.1. Research design, Samples, and Population

This is a descriptive cross-sectional study that was conducted among the general population in Makkah, KSA. The minimum sample size required for this study was calculated by OpenEpi version 3.01 18, in consideration of the following: the population size of the Makkah region is about 8.8 million inhabitants 19, keeping the confidence interval (CI) level at 95% and considering 50% prevalence of knowledge about GC. The sample size was calculated to be 385 participants. In case of any possible data loss, the total sample size came out to be 400 participants. We have included all members of the society who were eligible to answer our questionnaire. However, we have excluded any member with a previous history of cancers.

2.2. Questionnaire structure

The questionnaire was designed by Google forms 20 and distributed electronically via different platforms of social media. The language of the questionnaire was translated to Arabic (the native language of the participants) and then it was translated back to English for analysis and publication. The questionnaire was inspired by a previous study done in China 21 with some modifications related to the demographic data, and its reliability was evaluated. It was divided into four main sections. First section: the socio-demographic data, including 14 questions about gender, age, nationality, residence, marital status, educational level, occupation, income, working/studying in a medical field, family history of cancer or GC, health status, and any diseases of the upper gastrointestinal tract. Second section: identification of risk factors of GC, which included multiple-choice grid table with 16 risk factors, each risk factor consisted of three optional answers ("Yes", "No", and "Not sure/Do not know"), the risk factors were: old age, male gender, H.pylori infection, stomach ulcer, previous stomach surgery, atrophic gastritis, Family history of gastric cancer, salty diet, consumption of pickled foods, consumption of smoked foods, Irregular diet, frequent eating of leftovers, smoking, drinking, stress and frequent midnight snacking. Third section: identification of the warning symptoms of GC, including multiple-choice grid table with 6 warning symptoms and the same optional answers of the previous part, warning symptoms were: gastrointestinal bleeding, abdominal lump, abdominal pain, upper abdominal fullness, weight loss, and recurrent nausea and vomiting. Fourth section: perceptions on the screening for GC, consists of 6 multiple of choice questions, the first four of them were “yes, no” questions, included: do you think gastric cancer can be prevented? do you think early gastric cancer can be cured? do you think screening can help detect early gastric cancer? have you ever undergone gastric cancer screening? While the last two questions of this part were: why do you not undergo screening for gastric cancer? (Answers were: "do not know the benefits of screening", "fear of undergoing gastroscopy", "worried about screening results", "no symptoms", "no time" and "financial limitations"), and which screening method for gastric cancer would you prefer? (Answers were: "gastroscopy", "blood test" and "none of them"). To assess the population’s knowledge about risk factors and warning symptoms of GC, 22 risk factors and warning symptoms were listed in a multiple-choice grid table. One point was given for each of the factors or symptoms that the participant agrees to. For each participant, a maximum score of 22 was calculated. The participants’ knowledge was then categorized into three groups: Low level (0-7 points), Moderate level (8-14 points), and High level (15-22 points).

2.3. Statistical methods

Data were collected via an Excel sheet and then analyzed by using Statistical Package for social studies (IBM SPSS) version-23, Armonk, New York, IBM Corporation, USA. Variables were presented in numbers and percentages. Chi-square test was used to examine the association between gastric cancer knowledge and different socio-demographic data. A statistical significance was determined at p < 0.05.

2.4. Ethical Approval and Informed Consent

This research is exempted from research and ethical committee or an institutional review board (IRB) approval. https://www.hhs.gov/ohrp/regulations-and-policy/decision-charts-2018/index.html

An electronic informed consent was obtained from each participant prior answering of the questionnaire. Confidentiality was assured. Names or phone numbers were not requested from any participant.

3. Results

• Socio-demographic characteristics of the participants

A total of 400 participants were enrolled in the study. Table.1. represents the socio-demographic characteristics of all participants. In which, the participants' age was ranged from 14 to 65 years, and most of them were between 18-25 years (291, 72.8%). There were 296 (74%) female participants, while 104 (26%) were male. Most of the participants are Saudis (377, 94.3%), and 370 (92.5%) were residents in a city not in rural areas, as well as 295 (73.8%) were single. The educational level of 291 of the participants was a college or above (72.8%), and 281 participants were students (70.3%). The total income of 185 participants (46.3%) was less than 5000 SAR, 266 (66.5%) participants work/study in the medical field. The exact 135 (33.8%) participants have had a family history of cancer while 28 (7%) had a family history of GC. Most of the individuals were healthy (275, 68.8%), and 53 participants (13.3%) have complained of diseases of the upper gastrointestinal tract.

• Knowledge about risk factors and warning symptoms of GC

Table.2. represents the participants’ knowledge about risk factors and warning symptoms of GC. From the total of 400 participants, 78 (19.5%), 263 (65.8%), and 59 (14.7%) had respectively low, moderate, and high levels of knowledge about the risk factors and warning symptoms of GC (Fig. 1.). Only 3 participants had the full score (22 points). While 6 participants had zero in their score. The most highly recognized risk factors were family history of gastric cancer (83.8%), followed by alcohol drinking (81.8%), smoking (80%), H. pylori infection (65.5%), and stomach ulcer (64%). Less well-recognized risk factors included frequent midnight snacking (13.5%), salty diet (13.8%), and male sex (17.3%). The most highly recognized warning symptoms were gastrointestinal bleeding (77%), followed by recurrent nausea and vomiting (74%) and abdominal lump (73.5%). On the other side, less well-recognized warning symptoms include upper abdominal fullness (44.3%) and abdominal pain (58.5%).

• Participants perceptions on the screening of GC

As represented in Table.3, most of the participants (94.8%) thought that GC could be prevented, 389 (97.3%) thought GC could be detected early and only 12 (3%) thought early GC could not be cured. Furthermore, only 11 (2.8%) participants undergone screening of GC, all of them were older than forty years, which is the recommended age range for GC screening. Of the 389 participants who did not undergo screening, they were asked about the reason, and the commonest answers were: no symptoms (65.3%), no time (13.1%), and fear of undergoing gastroscopy (8.8%). All the participants were asked about the most preferred screening test for GC, 209 (52.3%) preferred blood test, 160 (40%) preferred Gastroscopy as a first option, while 31 (7.8%) chooses ‘none of them’.

• Association between GC knowledge and socio-demographic data of the participants

The outcome analysis for factors associated with knowledge of risk factors and warning symptoms of GC is represented in Table.4. In which, more than half of the participants aged between 18-25 years had recorded moderate levels of knowledge (68%), with a statistically significant p-value of 0.034. Regarding participants’ occupation, most students had moderate levels of knowledge (191, 68%), with a recorded statical p-value of 0.019. Participants who reported to have an income of less than 5000 SAR were also recorded the most levels of moderate levels of knowledge (125, 67.6%) compared to 39 participants (21.1%) who had low levels of knowledge, with a statical significance p-value of 0.003. Other associations between knowledge of risk factors and warning symptoms of GC and socio-demographic data of the participants are shown in Table.4.

4. Discussion

GC is still spreading worldwide, and the newly discovered cases annually increase the importance of public awareness towards the symptoms, screening, and available medical treatment. The early detection of GC to prevent, diagnose, and provide medical treatment for the patient is important. Therefore, during this study, it is cleared there is a good level of knowledge towards the disease itself but the awareness of the risk factors in order to prevent the possibility of disease occurrence is still a challenge for public health awareness programs. As a high intake of salty diet, lack of fresh fruits and vegetable intake, alcohol consumptions, and active use of tobacco is associated with increasing the chance of gastric cancer; a healthy diet and lifestyle are a must. Nevertheless, public understanding of the need for early GC screening especially for high-risk individuals remains a challenge for public health awareness.

As previously stated, our findings revealed that the mean score for GC knowledge was 10.7. And a total of 14.7% of the participants were recorded to have a low level of knowledge. This result is considered to be a good level of knowledge, and it is substantially higher than a previous study performed among China's general population 21. In which, they reported a mean score of 8.85/22 (SD 6.48), with a low level of knowledge within 47% of their participants. This might be owing to the large number of educated people that participated in our study, as 72.8% of our participants were studied in a college or above. On the contrary to the Chinese study, our findings were consistent with other studies conducted among Korean and Iranian populations 22,23. In regard to GC screening, our findings revealed only 2.8% of the participants undergone gastric cancer screening, while 15.2% had undergone the screening of gastric cancer among China's general population 21. These results indicated the public need for awareness regarding the importance of early screening to avoid possible complications of the disease. Our results showed that the knowledge of GC was differed according to the socio-demographic characteristics of the participants. Which were also reported in some previous studies 21,24. In particular, our findings revealed that younger individuals were more knowledgeable about GC than middle-aged and older individuals, this finding is concerning as GC is much more prevalent in individuals over the age of 40 years 25. Accordingly, we recommend awareness programs to educate the public and to be more focused on the age group of 40 years and above. Moreover, participants’ occupation, level of income, and having a previous family history of GC were reported in our findings to be significantly associated with the knowledge of GC. An additional association was reported in a previous study between the level of knowledge and gender 21, where females found to have better levels of knowledge than males.

To the best of the authors' knowledge, the following study is the first study conducted among the general population in Makkah city, KSA to assess their level of knowledge about GC. Nevertheless, we announce certain limitations in our study. First, the majority of responders were highly educated. Therefore, our results may not apply to all different structures of the population. Secondly, the small sample size of our study may increase the chance of errors. Therefore, we recommend conducting similar studies extended to the community with a larger sample size to confirm our results.

5. Conclusion

Good levels of knowledge about the risk factors and warning symptoms of GC were recorded to be moderate in most of the population in Makkah. However, the awareness of some risk factors as well as the awareness of the importance of early screening for GC especially for the individuals with high-risk is still a challenge for public health awareness. We recommend conducting similar studies extended to the community with a larger sample size to confirm our results.

Acknowledgments

The authors would like to extend their gratitude and acknowledgment to all the participants for their participation. We are in debt to Dr. Ying Zengfor 21 for inspiring us to do this study.

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