Colorectal cancer incidence has increased significantly in Saudi Arabia in the last few years. Although protocols and guidelines for colorectal screening programs had been established to start at age 45, adherence to screening remains low. This review aims to identify the potential barriers to participating in the screening program among the public aged over forty-five in Saudi Arabia. A significant lack of awareness about colorectal cancer and screening programs had found among Saudi Arabias public (SA). The acceptance rate significantly increased due to health care provider recommendations. Knowledge about colorectal cancer and screening program and outcome should be raised among the public through campaigns and physicians by training established for primary health care providers regarding screening programs recommendations.
Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading global cause of mortality (Keum and Giovannucci, 2019). More-over, it expected to rise the mortality rate globally to 60% by 2030 (Aziz and Allah-Bakhsh, 2018). In Saudi Arabia (SA), CRC is second-highest cancer. According to Saudi Cancer Registry data, it is the most common cancer among men and the third most common among women (Alsanea et al., 2015). Overall, the incidence of CRC in SA has significantly grown during the last few years to be the highest in the Gulf Cooperation Council (GCC) (Alyabsi et al., 2020).
The most affected age group was over 45, and a quar-ter had meta-static cancer (>70% diagnosed late). Conversely, other studies showed that around 25% were diagnosed with localized masses. The late-onset presentation group (diagnosed above 45) accounted for the highest incidence. Due to delays in seeking medi-cal attention, approximately one-quarter of late-onset presentations present distant metastasis. Adenocar-cinoma is the most frequent pathological variant, while grade 2 is the most common (Mosli and Al-Ahwal, 2012). More than half of diagnosed cases are spori-cidal with no predisposing family history or genetics (Keum and Giovannucci, 2019).
Globally, the CRC incidence rate corresponds to grow-ing environmental risk factors such as smoking, sedentary lifestyles, and physical inactivity (Keum and Giovannucci, 2019). As in the GCC, the SA showed the same epidemiological distribution as that occurring globally. Smoking, high caloric intake, and physical inactivity have rapidly increased in the last few years in the KSA, contributing to non-communicable dis-eases, as cancer is rising parallelly. However, some studies show that consuming sufficient fruits and vege-tables, black tea, coffee, and olive oil had a protective effect against developing CRC (Allauddin et al., 2021). Yet, other studies showed that a minimum per-centage of the Saudi population had consumed five portions of vegetables and fruits. Additionally, increa-sing red meat consumption due to the availability of fast foods increases the risk of increased caloric intake and thus of CRC (Alyabsi et al., 2020).
Inflammatory bowel disease (IBD), such as ulcerative colitis (UC) and Crohns disease (CD), has a pro-gressive correlation with developing colon cancer. CD patients are 20 times more at risk of developing CRC than similar populations (Freeman, 2008). Similarly, UC increases the risk by 2%, then by 8%, then by 18% every ten years (Lakatos and Lakatos, 2008). The inci-dence of IBD in SA has not been estimated. Pediatric incidence doubled in the last 20 years, reflected in an increasing adult incidence rate (Saudi et al., 2012). The central area, Makkah City, and the Eastern region reported the highest prevalence in the pediatric age group (El Mouzan et al., no date). It is noteworthy that the Eastern province may have the highest rate of CRC because of the oil and petrol industries (Alyabsi et al., 2020).
Evidence has indicated that early detection would imp-rove outcomes and reduce mortality (Alduraywish et al., 2020). Since 2015, the Saudi National Program has recommended CRC screening for asymptomatic indi-viduals aged >45. Subsequently, the median age of diagnosed CRC in Saudi males was 60, while it was 55 in Saudi females (Alsanea et al., 2015). A colonoscopy every ten years is the gold standard for CRC screening, and more than 70% of the populations are willing to have one. However, there is a shortage of endoscopists in SA. Flexible sigmoidoscopy (FS) is a cost-effective alternative to colonoscopy and requires no sedation or preparation. However, it carries more risk of compli-cations such as perforation, bleeding, or death. Further-more, it has limitations regarding detecting right colon polyps or adenocarcinomas (Alsanea et al., 2015). Un-like colonoscopy, FS must be repeated every five years with annual fecal immunochemical testing (FIT) or every three years without annual FIT (Alsanea et al., 2015). In the United States, the most common reason for not using CRC screening is a lack of public aware-ness of the importance of undergoing screening and insufficient physician recommendation of CRC scans (Klabunde, Schenck and Davis, 2006). Another cross-sectional study of 660 patients aged over 75, con-ducted in Virginia, showed that the most common cause is fear of bowel preparation before colonoscopy, followed by an absence of medical advice and lack of knowledge and free time (Jones et al., 2010). Several regional research attempts in the SA were conducted within the last ten years to address knowledge, attitude, and practice (KAP) toward CRC and potential reasons for public and health care providers to resist CRC screening have influenced the marked increase in incidence in the KSA, which has burdened health care. However, to the best of our knowledge, the adherence and acceptance rate of CRC screening remains limited, reflected in an increased incidence of colon cancer. Moreover, data is little concerning potential public barriers to participating in the CRC screening (CRCS) program in SA. Therefore, this review aims to identify the knowledge, borders, and possible challenges con-cerning CRC screening in the SA population aged over 45 years.
The study has been conducted as a narrative review. For the last 20 years (2000 - 2020), PubMed research has examined using multistage strategies to review all free access published papers on CRC screening in SA. In addition, cross-sectional studies had included asses-sing the knowledge, attitudes, and practices con-cerning CRC screening and barriers relating to the public, medical students, and physicians.
Fig. 1: Sampling Protocol.
All articles concerning SA have been included that were available as free full text. First, the following search terms had been used: “colorectal cancer” OR “CRC screening” OR “CRCS” and “Saudi” OR “SA” OR “KSA.” The articles were then manually filtered by reviewing the titles and abstracts to select the studies that achieved this reviews purpose, as shown in Fig. 1. Finally, the fifteen studies included in this review have been listed and summarized in Table 1.
Knowledge about CRC
In the capital city of SA, Riyadh, a cross-sectional study has been conducted of 484 Saudi participants aged over 45, illustrating that about 69% had heard about CRC. Furthermore, of 484 participants, 20.1% had a relative with CRC (Alduraywish et al., 2020). Moreover, in one of the largest oases in the world, in the Eastern province in SA, Al-Ahsa Governorate, a large cross-sectional study (947 participants) was con-ducted; 77% of participants had heard about CRC, and 12.8% had a family history of CRC (Galal et al., 2016a). Another cross-sectional study was conducted in the Southwestern region of SA, particularly in Asir, to assess public awareness about CRC. However, the mean level of understanding of CRC was 30.5% of a random sample of the Asir population (1,209 people), with approximately one-fifth (21.7%) aged over 40. Another cross-sectional study in the Western region targeted 581 medical students, showing that slightly more than half of those grade 5 and above scored poorly on knowledge about CRC (54.78%) (Althobaiti and Jradi, 2019). In an additional survey conducted in King Abdulaziz University targeting 525 unregulated students, half in the medical faculty, 82.3% had awar-eness about CRC, and more than half (68%) thought it was a preventable disease (Imran, 2016; Zubaidi et al., 2015a; Alshammari et al., 2020; Al-Sharif et al., 2018) found that the level of knowledge increased with age (for ages over 50). Furthermore, having a family history of CRC, a higher education level, and being female were positive factors in increasing awareness according to Al-Sharif et al. Al-Hajeili et al. and another study conducted in Riyadh city by Alshammari et al. of 231 subjects (p = 0.001) a family history of CRC (Alshammari et al., 2020; Al-Sharif et al., 2018; Al-Hajeili et al., 2019). Conversely, two of the 15 studies showed no relationship between awareness about CRC and a family history of CRC, gender, edu-cation level, occupation, and income (Al-Hajeili et al., 2019; Almadi et al., 2015) the level of knowledge did not affect willingness to undergo CRC screening (10.7 vs. 10.0, p = 0.13) (Almadi et al., 2015). Nonetheless, as Almadi and Alghamdi et al. found in a national survey to assess the gap between knowledge and wil-lingness to undergo CRCS for 5,720 individuals, most of whom were male, there was no significant differ-ence in knowledge between all 13 KSA jurisdictions. Additionally, no significant difference in understand-ding was found between males and females, nor among those willing and unwilling to undergo CRCS (Almadi and Alghamdi, 2019).
Table 1: Summary of Studies.
Knowledge about Risk Factors
Almadi et al. stated that significant percentages of people identified alcohol intake, poor diet, IBD, family history, and smoking as risk factors for developing CRC (62.2%, 54.2%, 50.8%, 37.6%, and 35.3%, res-pectively) (Almadi et al., 2015). Moreover, obesity (22.1%), age (19.3%), diabetes (7.8%), hypertension (7.4%), and sex (6.8%) were also considered as risk factors. However, 13.9% knew no CRC risk factors (Almadi et al., 2015). Again, in the Western region, a reported family history of CRC (77.59%) and age (67.76%) were considered risk factors for CRC. Fur-thermore, 61.1% reported diet as another risk factor, followed by smoking (60.96%). Other risks identified as male gender, IBD, and inadequate physical activity (48.79%, 44.79%, and 34.48%, respectively) (Altho-baiti and Jradi, 2019). Approximately 50%–60% of students were aware of the risk factors and symptoms of CRC, and nearly 4% had a family history of this cancer (Imran, 2016). Nonetheless, as Alshimmari et al. found, approximately 30%-50% of participants correctly identified risk factors of CRC (Alshammari, Alenazi and Alshammari, 2020). Most of the parti-cipants in the Al-Ahsa population did not know about CRC risk factors (66.4%) (24), and a positive relation-ship found between the experience of CRC screening and knowledge about CRC risk factors (p = 0.029) (Lakatos and Lakatos, 2008). However, in the Asir region, 2.9% gave correct answers concerning CRC risk factors (Al-Sharif et al., 2018). Alnuwaysir found in his survey, which had conducted in Dammam City, that more than half of the participants were aware of the risk factors of CRC (Alnuwaysir et al. and Marwan et al. stated that higher income levels had a statistically significant relationship with age as an important risk factor of CRC (Al-Hajeili et al., 2019). Furthermore, a survey of 1,070 participants in Riyadh indicated that 80.6% did not know that colon polyps and family history increase the risk of developing CRC. However, higher levels of education has linked with better information ( Aziz and Allah-Bakhsh).
Knowledge about the Screening Program
Imran et al. stated that most participants (77%) thought early CRC detection couldachieved by screening, and one-third were aware of screening tests (Imran, 2016). However, Al-Hajeili et al. showed that hearing about screening programs and sigmoidoscopy was more likely for those with a higher education level, were female, or had a relative with CRC (Al-Hajeili et al., 2019). In addition, a high percentage of responders (42.9%) thought a CRC screening test has conducted once symptoms started, and around a quarter thought CRC started at age 50, based on a questionnaire con-ducted in Riyadh in 2015 (Al-Khayal et al., 2016). Similarly, Alshammari et al. stated that approximately half the participants had heard about CRCS, nearly half knew about colonoscopy, and about a quarter had heard about blood-based screening tests (Alshammari, Alenazi and Alshammari, 2020). Nevertheless, a quar-ter of participants was interested in undergoing scree-ning. Although one-fifth thought their knowledge of CRC was insufficient, the acceptance rate would be tripled with a physicians advice (Alshammari, Alenazi and Alshammari, 2020). In the Western region of the KSA, Khayyat and Ibrahim et al. found that only one-third of 313 participants had heard about CRCS (Khayyat and Ibrahim, 2014). Almost half the part-icipants (50.56%) knew about colonoscopy, followed by computed tomography colonography (CTC), stool-based screening, and FS (32.7%, 24.7%, and 14.7%, respectively). In addition, some participants thought a complete blood count (CBC) sample could detect the presence of CRC (21.9%), while 19.9% had not previously known about screening tests (Almadi et al., 2015). Most medical students thought the most effect-tive screening method was sigmoidoscopy (71.95%), followed by colonoscopy and FOBT (60.76% and 30%, respectively). However, less than half (41.14%) did not consider a double-contrast enema an effective screening tool (Althobaiti and Jradi, 2019). As Almadi et al. mentioned, in the national survey of 5,720 part-icipants, most were over 43, yet less than one-sixth (15.24%) had already screened for CRC (Almadi and Alghamdi, 2019). Nonetheless, colonoscopy was the most used screening tool (72.73%), followed by FOBT (13.94%) and finally FS (4.85%) (Almadi and Algh-amdi, 2019). Moreover, most people (75.85%) thought colonoscopy was practical, and more than two-thirds considered CRC curable (63.5%) (Almadi and Algh-amdi, 2019). The majority (70.7%) was willing to have a screening test, and the percentage increased for those having a relative with CRC (83%). Furthermore, knowing the risk factors significantly improved willin-gness to undergo a colonoscopy (80.6% vs. 68.2%, 95% CI: 1.11–3.40, p = 0.02, OR 1.95) (Almadi et al., 2015). Alduraywish et al. stated that 12.5% of 484 participants had a history of CRCS and found more than a third uptake of CRCS from the 41–50 age group (36.4%). Moreover, most participants had screened once, followed by three times and more, then twice (55%, 22%, and 32.2%, respectively). Furthermore, 55.4% had screening procedures as a routine checkup concerning the reasons for undergoing screening. In comparison, a quarter (26.8%) had abdominal pain or a history of painful defecation. Around one-fifth (21.4%) had IBD history (Alduraywish et al., 2020). Colon-oscopy was the most common screening tool used, followed by FOBT (73.2% and 57%, respectively) (Alduraywish et al., 2020). Additionally, most res-ponders in the national survey showed their willing-ness to undergo CRCS (73%). Having a relative or friend with CRC raised the rate to 80%, with the same acceptance rate of colonoscopy as a screening tool (80%). However, the acceptance rate increased if the procedure was paid for (92%) rather than provided free of charge (56%) (Almadi and Alghamdi, 2019). Con-versely, in the Western region of SA, Khyyat and Ibrahim et al. responses to questionnaires showed nearly two-thirds (62.9%) were unwilling to undergo any CRCS procedure (Khayyat and Ibrahim, 2014).
Nonetheless, Galal et al. indicated a low rate (8.6%) of participants (947) with experience of CRCS (24). Furthermore, being an unmarried female (OR = 0.28; p = 0.001; 95% CI = 0.14-0.57), having a lower edu-cation level (OR = 0.36; p = 0.015; 95% CI = 0.16–0.82), having no family history of CRC had a sign-ificant association with refusing screening(OR = 0.30; p = 0.001; 95% CI = 0.17–0.56)(24).
Barriers to Screening
Fear of the result was the most prominent barrier (39%) to colonoscopy. However, most responders dis-agreed with believing colonoscopy is a harmful pro-cedure. Moreover, the barrier of being an embarrassing technique was not significant among res-ponders in the national survey (Almadi and Alghamdi, 2019). How-ever, regarding CRCS barriers, around a quarter of subjects were unaware of the need to have a screening test. In contrast, another quarter thought they did not need to undergo it if they were asymptomatic. Addi-tionally, less than a 10th mentioned fearing embarrass-sing procedures or lack of time as a reason to refuse to screen (Alshammari et al., 2020). Additionally, in the Jeddah survey, 2018, the cost of screening tests, dis-comfort, and even fear about the result were not bar-riers to screening. However, fear of the procedure was a significant barrier (CI = 0.19–0.75, p = 0.005) (Al-Hajeili et al., 2019). However, Almadi et al. stated that neither being pro-vided free nor having to pay did not affect acceptance of screening, according to a large cross-sectional study conducted in Riyadh (Almadi et al., 2015). Instead, fear of being harmed or not wanting to know about the presence of cancer were the only factors in refusing a screening test (Almadi et al., 2015). Alduraywish et al. found that the primary factor reported as a barrier was insufficient physician recom-mendation, followed by the absence of worrying signs and symptoms (77.1% and 73.4%, respectively). Lack of knowledge of CRC and the importance of CRCS (51.1% and 19.2%, respectively) were cited together with lack of social support (49.5%) (Alduraywish et al., 2020). It is noteworthy that slightly more than two-thirds of responders cited fear of the procedure (31.7%) and fear of the result (36.4%) as barriers to CRCS (Alduraywish et al., 2020). The majority men-tioned lack of knowledge and health provider aware-ness about the CRCS program, followed by lack of physician recommendation and discussion, as major barriers in the Al-Ahsa community (68.7% and 67.3%, respectively). In addition, a small proportion reported financial burdens and transportation issues (15% and 5.4%, respectively) (24). Moreover, fearing harm (51. 6%), followed by inadequate knowledge of who would perform the screening (50.9%) and unknown avail-ability of tests (43.8%) had reported as specific barriers to colonoscopy. However, the absence of FOBT (57.8%) and no time to test (34.2%) were the only issues reported regarding the FOBT screening method (Alduraywish et al., 2020). Moreover, the study by Alduraywish et al. supported that being female had a significant association with personal barriers such as lack of know-ledge about CRC and fear of the procedure and result (p = 0.015). However, no difference was found between males and females regarding religious beliefs, shyness, or lack of trans-portation (p = 0.085; p = 0.061, respectively)(Alduray- wish et al., 2020). Being female had a more significant association than being male with most of the personal barriers, such as shyness (51.4% vs. 23.5%, p = 0.001), fear of the result (50.9% vs. 38.6%, p = 0.001), fear of a painful screening procedure (41.9% vs. 34.7%, p = 0.041), and lack of confidence in health care pro-viders (59.3% vs. 29.3%, p = 0.001). However, lacking time was reported more by males (55.8% vs. 43.8%, p = 0.001) (24). Moreover, among medical students, the major patient-related factors reported were fear of the result (65.72%), followed by feeling anxious or embarrassed, lacking knowledge, and no symptoms (53.1%, 52.76%, and 51.21%, respectively) (Althobaiti and Jradi, 2019). Among medical student surveys conducted recently in 2019, students reported some health system-related factors such as lack of patient CRC knowledge as the most common barrier to screening (OR = 0.74; 95% CI: 0.40–0.71). In addi-tion, Asma et al. suggested unavailability of suffi-ciently trained endoscopists to follow up the patients was one barrier facing the screening program (OR: 0.58; 95% CI: 0.44–0.78) (Althobaiti and Jradi, 2019).
However, they reported some health system factors such as insufficient attention to guidelines concerning CRCS (57.76%), unavailability of the test (56.38%), lack of health care recommendations (45%), and shor-tage of trained endoscopists and other health care providers (42.24%) (Althobaiti and Jradi, 2019). In studying physician barriers, Mahmud et al. showed that male physicians (OR = 0.44, p = 0.05, 95% CI = 0.19–0.99) and lower qualified PHC physicians (OR = 0.72, p = 0.01, 95% CI = 0.55–0.93) were less likely to adhere to CRCS recommendations (Mosli et al., 2017).
The vast majority (80%) of physicians who did not perform screening tests reported lack of time as a significant barrier, followed by 77% reporting diffi-culty in understanding CRCS recommendations. App-roximately (70%) of participant physicians stated that they refused to discuss CRC with patients. Slightly more than half (60.3%) thought patients do not consider it a serious health condition (Demyati, 2014). However, 83.3% of physicians reported the unavaila-bility of clear guidelines in their work. Physicians trained and untrained in CRCS significantly differed regarding practicing screening (77.8% vs. 54.5%; p = 0.04) (Demyati, 2014). While assessing physician-related barriers, Mosli et al. conducted cross-sectional studies to determine the knowledge, attitude, and prac-tice of PHC physicians regarding CRCS in Jeddah. The finding showed a significant difference between physicians knowledge based on having a board grade or Ph.D., being trained in family medicine, and having experience in practicing CRCS (p < 0.01). Similarly, following the United States Preventive Services Task Force (USPSTF) also led to a significant difference in knowledge about CRCS (4.2 ± 2.1 vs. 3.1 ± 1.9, p < 0.01). However, the availability of a reminder system had no role as a barrier to CRCS (Mosli et al., 2017).
However, Demyati et al. conducted another cross-sectional study showing that physicians reporting the absence of a reminder system had a worse attitude toward CRCS (p = 0.001) (Demyati, 2014). Although they also showed that men reported a better screening attitude than women physicians (p = 0.02), no signi-ficant difference was found between men and women in CRC screening (p = 0.063) (Demyati, 2014). More-over, physicians older than 40 showed superior atti-tudes to younger physicians (p = 0.047) (Demyati, 2014).
Moreover, a study by Demyati et al. supported a study by Mahmud, indicating that following USPSTF or other recommended guidelines resulted in the better practice of CRCS (p = 0.025). Moreover, physicians with board certificates were more knowledgeable than general practitioners (p = 0.009) (Demyati, 2014).
Studies focusing on addressing the possible barriers to the Saudi population rather than knowledge of the health system were limited. Nonetheless, samples used in the review were not representative of the SA popu-lation due to different target age groups, including non-Saudi models. Additionally, some regions of the KSA had not been recruited, such as the Northern region. Thus, further national studies have been req-uired that assists in identifying and understanding the situation to improve the screening program in SA. Moreover, improving health education for PHC phy-sicians and the public is required to remove these barriers to facilitate CRC screening.
Although the presence and established screening pro-gram in SA to early detection of CRC, it is not well operated. A poor percentage of adherences indicate the need for further health promotion and education to increase awareness for the public and health care providers. The findings of this review advocate increa-sing health education and public awareness to improve CRCS and general adherence among the target age group in SA. Based on a previous study, lack of know-ledge and awareness was the most significant barrier to adherence to screening in the UK, followed by fear of the result and frequency of the procedure, according to a study conducted in 2007 (Austin et al., 2009). Addi-tionally, religious beliefs had a role among females (Austin et al., 2009). Other studies have demonstrated a lack of physician recommendations, social support related to fear of a result, insufficient knowledge about CRC, and negative mindsets regarding screening tools (Ma et al., 2012). Many other studies supported a strong association with health care provider coun-seling. Short, direct discussions about CRC screening programs and tools positively impacted patients behaviors and attitudes to CRC screening (Fenton et al., 2011).
We would like to thank the peer reviewers for their valuable comments and suggestion.
There are no potential conflicts of interest for the authors to disclose.
Academic Editor
Dr. Phelipe Magalhães Duarte, Professor, Department of Veterinary, Faculty of Biological and Health Sciences, University of Cuiabá, Mato Grosso, Brazil.
Ministry of Health, Eastern Province, Saudi Arabia.
Alhaddad JA., and Alessa M. (2022). Barriers toward colorectal cancer screening among public in Saudi Arabia. Eur. J. Med. Health Sci., 4(2), 55-63. https://doi.org/10.34104/ejmhs.022.055063