Role of Primary Healthcare Physicians in Early Detection of Colorectal Cancer in Al-Ahsa, Saudi Arabia

Introduction: Colorectal cancer (CRC) is the third most common cancer in Saudi Arabia. Late stages of the disease are associated with increased mortality rates, and early detection is known to improve the disease course and significantly reduce the mortality rate. Physicians’ knowledge and practices regarding CRC screening guidelines influence the successful implementation of screening programs. Understanding them is key to developing targeted interventions to enhance screening rates and promote early detection. Methods: This study was a cross-sectional assessment of the current practice and knowledge of CRC screening among healthcare practitioners in Al-Ahsa, Saudi Arabia, by using a questionnaire. This questionnaire had seven multiple-choice questions to assess knowledge and six multiple-choice questions to assess physicians' attitudes toward CRC screening. Results: The mean age of participants was 33 years; 60.8% (n=113) were men and 39.2% (n=73) were women. The majority were Saudi nationals (n=169; 90.9%). Self-assessed knowledge levels varied: 42.5% considered their knowledge of CRC screening adequate, 27.4% indicated that it was poor, and 30.1% reported that it was satisfactory. Positive attitudes towards CRC screening were expressed by 83.9% of participants. Also, physicians’ attitude scores varied by demographic factors. Significant correlations were found between attitude scores and marital status, medical qualification, and job title. There was no significant correlation between gender, nationality, and years of experience. The majority (75.3%) agreed that colonoscopy is the best available screening test, but highlighted issues with accessibility and actual availability. Conclusion: Findings from this study provide insights into physicians’ knowledge, attitudes, and practices regarding CRC screening. Understanding these factors is crucial for developing effective interventions to enhance CRC screening rates and overall public health. Further education and standardized guidelines are recommended to address the variations observed in the study population.


Introduction
Colorectal cancer (CRC) arises due to uncontrolled cell replication in the colonic mucosa [1].Many different types of CRC have been discovered and are classified based on histopathological appearance [2].Numerous risk factors contribute to the progression of CRC, including genetic predisposition, level of physical activity, nutritional pattern, obesity, smoking, and alcohol intake [3].CRC has the third-highest incidence rate and the second-highest mortality rate worldwide [4].It is most common in industrialized countries due to sedentary lifestyles [5].CRC was the most common cancer in Saudi Arabia in 2020, accounting for 14.04% of all cancers [6].Colonic and rectal cancers were respectively the third and sixth most common causes of death among individuals with cancer in Saudi Arabia in 2020 [6].
When CRC treatment begins at an early stage of the disease, the outcomes improve significantly, while worse prognoses are associated with the metastatic stages [7].Screening programs can significantly improve disease outcomes by identifying cases at an early stage.CRC screening in Saudi Arabia should ideally begin at 45 years of age [8].However, the average age of CRC detection in men and women has been reported to be 60 and 55 years, respectively [9].A study with approximately 3,000 participants with an average age of 70 years found that the CRC screening rate was only 5.64% [10].Many factors potentially contribute to the low rate of CRC screening, including lack of physician knowledge and practice.For example, one study found that only 55% of primary healthcare physicians in Saudi Arabia followed CRC screening guidelines [11].In addition, there may also be low awareness of the importance of CRC screening [12].The aim of this study was to assess whether primary healthcare physicians in Alhassa, Saudi Arabia, are following CRC screening guidelines.

Materials And Methods
This was a cross-sectional study conducted from March 2023 to May 2023 targeting physicians in primary health care centres (PHCs) in Al-Ahsa region.Data was collected by filling electronic questionnaire by interviewing the doctors.A total of 186 participants were included, calculated taking a 5% margin of error, and a 95% confidence interval.The study was approved by King Faisal University, Al-Ahsa, Saudi Arabia (approval number: KFU-REC-2022-DEC-ETHICS413).
The questionnaire used in this study was adapted from a validated questionnaire on the screening of colorectal carcinoma as described by Mosli et al. [11].Seven multiple-choice questions were used to assess knowledge, and six multiple-choice questions were used to assess the attitudes of physicians toward CRC screening.Each accurate answer was scored as 1 point, whereas each wrong or "do not know" response received a score of 0. Bloom's classification cutoff points for knowledge were applied: a knowledge score between 75% and 100% was regarded as adequate; a score between 50% and 74% was satisfactory; and a score of less than 50% was considered poor.A score greater than the mean was indicative of a positive attitude, while a score less than the mean indicated a negative attitude.Cronbach's alpha was used to assess the internal consistency and reliability of a set of items within a questionnaire or scale.
The analysis included both descriptive and inferential statistical tests.Descriptive statistics were used to summarize and describe the characteristics of the study participants and the questionnaire findings.Frequencies and percentages were calculated for categorical variables.For continuous variables such as knowledge and attitude scores, the mean and standard deviation were calculated for normally distributed variables, and the median and interquartile range were used for non-normally distributed variables.The normality of the data was assessed using the Shapiro-Wilk test.Due to the non-normal distribution of the data, the independent-samples Kruskal-Wallis test was used to compare knowledge and attitude scores between different demographic groups.Fisher's exact test was used to examine the association between demographic characteristics and CRC screening practice.The significance level for all statistical tests was set to P < 0.05, indicating a 95% confidence interval.All statistical calculations were performed using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, New York, United States).

average-risk patients
The median knowledge score was the same for both female (4) and male (4) physicians (Table 9).The interquartile range for both genders also showed similar patterns, with female physicians having a slightly larger range (4-6) than male physicians (5-6).Physicians of Saudi nationality had a significantly higher median knowledge score (4) compared with non-Saudi physicians (2).Knowledge scores were similar between physicians of different marital statuses.Those with a Board or PhD in Family Medicine qualification had the highest median knowledge score (5), followed by MBBS (3), Diploma or Master's degree in Family Medicine (2), Diploma or Master's degree in another specialty (1.5), and Board or PhD in another specialty (1).This difference was statistically significant between the groups (p-value=0.001).The reported number of years of experience was not significantly associated with the average knowledge score.However, consultants had the highest median knowledge score ( 5), followed by specialists ( 5), and residents (3).This difference was statistically significant (P = 0.001).

TABLE 10: Level of knowledge of colorectal cancer screening among physicians
The median attitude score was the same for both female (5) and male (5) physicians (Table 11).The interquartile range for both genders was also the same, suggesting that gender did not significantly influence participants' attitudes toward CRC screening.Attitude scores were not significantly different between Saudi (5) and non-Saudi (6) physicians, but they did differ by marital status.Divorced physicians had a median attitude score of 4.50, married physicians had a higher median score of 6, and single physicians had a median score of 5.This difference was statistically significant (P = 0.029).Physicians with a Board or PhD in Family Medicine or Board or PhD in another specialty had the highest median attitude score (6), followed by MBBS (5), Diploma or Master's degree in Family Medicine (4), and Diploma or Master's degree in another specialty (3.5).This difference was statistically significant (P = 0.001), suggesting that specialized qualifications in Family Medicine were associated with more positive attitudes.Years of experience did not appear to have a significant impact on attitudes (P = 0.420), and the median attitude scores were consistent across different experience levels.However, significant differences were observed based on job titles.Consultants and specialists had the highest median attitude score (6), followed by residents (5).This difference was statistically significant (P = 0.003).

MBBS: Bachelor of Medicine and Bachelor of Surgery
There was no significant difference in screening practices between physicians who reported being influenced by clinical evidence in published literature or guidelines, and those who did not (Table 14).However, a significant difference was found between those who reported being influenced by the availability of providers, their colleagues' practice, or patient preferences, and those who did not.

Discussion
CRC is a significant global health concern, ranking among the most common and deadly cancers.Early detection and effective screening programs play a vital role in reducing CRC-related morbidity and mortality.A recent study found that CRC screening prevalence is very low [10].However, physicians can be pivotal in guiding patients toward appropriate screening methods and recommendations.This study aimed to explore the knowledge and practices of family medicine physicians in Saudi Arabia regarding CRC screening.The results shed light on current practices and identify areas for improvement [8].
Our study found diverse CRC screening knowledge and practice patterns.Most participants (n=128; 68.8%) recommended initiating CRC screening at age 50, and 20.4% (n=38) suggested age 40.Surprisingly, 3.8% (n=7) proposed initiating screening at age 60.Another study reported that 64% of participants believed that most asymptomatic, average-risk patients should commence screening at the age of 45 years [11].There were discrepancies in recommendations for screening frequencies in the current study, such as 60.2% (n=112) favoring annual FOBT screening and 48.9% (n=91) suggesting colonoscopy every 10 years.Similarly, variations emerged in opinions on the age at which screening should start and stop.These findings are similar to those of a study conducted in Riyadh [11].
Physicians displayed predominantly positive attitudes towards CRC screening.Almost all believed CRC screening for asymptomatic average-risk patients aged 50 years and above to be effective.Positive attitudes were observed toward various screening methods including FOBT, flexible sigmoidoscopy, colonoscopy, double-contrast barium enema, and CT colonography.These attitudes were similar to the findings of a study by Alghamdi et al., which also showed that a majority of participants had a positive attitude toward CRC screening [13].
Our study identified barriers affecting CRC screening practices.Some physicians reported a lack of policies and procedures for screening (n=64; 34.4%) and a shortage of trained providers of non-FOBT methods (n=116; 62.3%).Patient adherence issues were reported by 54.3% (n=101) of participants.Factors influencing screening decision-making included clinical evidence in published literature, the United States Preventive Services Task Force recommendations, the American Cancer Society guidelines, availability of investigation providers, colleagues' practices, and patient preferences.This is in contrast to the findings of a study conducted in Malaysia, where the most common barrier stated by the primary care providers was "unavailability of the test" [14].The two most common patient factors were "patient in a hurry" and "poor patient awareness." Certain demographic characteristics were found to be related to participants' knowledge and attitudes.Saudi nationality, specialized medical qualifications in family medicine, and the job titles of consultant and specialist were associated with higher knowledge scores.These results were comparable to another study [11].Marital status (being married) and specialized medical qualifications in family medicine were linked to more positive attitudes towards CRC screening in our findings.However, no association was found in the study by Mosli et al. [11].
Nationality, medical qualification, and job title were significantly associated with CRC screening practices among healthcare professionals.Tailoring interventions based on these demographic factors could enhance CRC screening rates and early cancer detection.The findings demonstrated statistically significant associations between recommendations for CRC screening and factors such as the availability of providers (P = 0.004), colleague practices (P = 0.001), and patient preferences (P < 0.001).However, other factors such as clinical evidence and guidelines did not significantly influence recommendations.This finding is in contrast to another study that reported that physicians whose practice was influenced by the United States Preventive Services Task Force and American Cancer Society recommendations reported practicing CRC screening more than those who were not influenced by these resources [15].
The findings of this study have significant implications for enhancing CRC screening practices.Physicians' knowledge gaps and variable practices highlight the importance of continuous medical education and standardized guidelines [14].Efforts to improve patient adherence, streamline screening policies, and address provider shortages are crucial for the implementation of effective screening.Moreover, understanding the factors that influence physicians' attitudes can aid in tailoring interventions to promote more positive attitudes toward CRC screening [16].This study contributes to the ongoing efforts to reduce morbidity and mortality associated with CRC through informed and effective screening practices.
There were some limitations to our study.The participants were from a specific geographical location and may not be representative of physicians beyond this area.Additionally, the study relied on self-reported data, which can introduce bias.Future research could include the effectiveness of targeted interventions to address the knowledge gaps and barriers identified in this study.Comparative studies across different healthcare systems and regions could provide a more comprehensive understanding of the challenges and opportunities in CRC screening practices among physicians.

Conclusions
Our research sheds light on CRC screening knowledge, attitudes, and practices among physicians.Demographics such as nationality, qualification, and job title were linked to varying levels of knowledge and attitudes regarding CRC screening.Saudi physicians and those specializing in Family Medicine displayed higher CRC screening knowledge.Married physicians also held more positive attitudes.Job title and medical qualification played a role, with consultants and specialists indicating better understanding and attitudes.Most participants viewed CRC screening positively, although a notable number showed negative attitudes, indicating a need for targeted education.Factors affecting screening practices included referral availability, colleagues' practices, and patient preferences, which represent local and patient-centric influences.The study underscores the importance of tailored interventions to enhance CRC screening rates and ultimately improve patient outcomes.

TABLE 1 : Demographic data of the study participants
MBBS: Bachelor of Medicine and Bachelor of Surgery

Table 2
For the majority of your asymptomatic patients with average risk, you will start screening at age of:

Table 3
presents the participants' perceptions of the effectiveness of various screening procedures in reducing CRC mortality among average-risk patients aged 50 years and older.When asked about overall effectiveness, an overwhelming majority (n=181; 97.3%) of participants expressed belief in its effectiveness, with only 2.7% (n=5) responding negatively.Question Response n % Do you think that colorectal cancer screening for asymptomatic average-risk patients aged 50 years and older is effective?No 5 2.7 Yes 181 97.3 How effective do you believe the following screening procedures are in reducing colorectal cancer mortality in average-risk patients aged 50 years and older?

Table 4
presents the practice patterns of study participants concerning CRC screening.The majority (n=155; 83.3%) reported performing CRC screening for asymptomatic patients with average risk aged 50 years and older.However, 16.7% (n=31) indicated that they did not order such screenings.

TABLE 4 : Practice of colorectal cancer screening
FOBT: fecal occult blood test

TABLE 5 : Screening test combinations discussed with patients
There is no policy and procedure in my workplace for screening.There is a shortage of trained providers to provide follow-up of positive screening tests with invasive endoscopic procedures.
A significant proportion of participants (n=64; 34.4%) indicated that their workplace does not have a policy or procedure in place for CRC screening (Table6).Participants also reported variations in the presence of reminder systems for screening in their workplace; 73 (39.2%) indicated that reminders are usually available.Patient adherence presented challenges, with 54.3% (n=101) of participants reporting that patients sometimes do not follow through to complete CRC screening tests.The availability of trained providers of procedures was also an issue; 61.3% of participants indicated a shortage of providers of non-FOBT screening tests sometimes or usually, and 56.5% of participants reported a shortage of providers of procedures for follow-up on a positive screening test.

TABLE 6 : Barriers to colorectal cancer screening for asymptomatic, average-risk patients
The published literature and guidelines influenced screening recommendations.A total of 143 participants (76.9%) indicated that clinical evidence in the published literature shapes their recommendations for CRC screening, while 75.8% (n=141) reported considering the United States Preventive Services Task Force recommendations and 76.3% (n=142) cited the American Cancer Society guidelines (Table7).Locally, the availability of providers for referral beyond FOBT screening was deemed influential by 71.0% (n=132) of participants, and over half were influenced by the practice of their colleagues (n=114; 61.3%) or preferences of their patients (n=123; 66.1%).These results suggest that local practices and experiences contribute to shaping individual providers' approaches to CRC screening.

TABLE 7 : Factors that influence recommendations for colorectal cancer screening in practice When
It is the best available screening test.
asked specifically about colonoscopy, 140 participants (75.3%) agreed that colonoscopy is the best available screening test, although only half agreed that it is readily available for their patients (Table8).Some respondents (n=62;33.3%)disagreed that it is the best available screening test, potentially indicating issues with accessibility or availability of colonoscopy services.A majority (n=103; 55.4%) agreed with the statement that specialists able to perform colonoscopies are often too busy to conduct them for screening purposes.

TABLE 9 : Knowledge score compared by demographic characteristics
MBBS: Bachelor of Medicine and Bachelor of SurgeryAmong the participants, 42.5% (n=79) had adequate knowledge of CRC screening (Table10), and similar proportions had satisfactory or poor knowledge.

TABLE 14 : Colorectal cancer screening practice influences by different guidelines
FOBT: fecal occult blood test