Knowledge and Awareness of Screening for Prostate Cancer Risk Factors and Symptoms Among the General Population in Tabuk City, Saudi Arabia

Background Early-stage prostate cancer may not show any signs. Digital rectal examination and the prostate-specific antigen test are frequently used in the screening for prostate cancer. The objective of this research is to assess the knowledge and awareness of screening prostate cancer among males in Tabuk, Saudi Arabia. Methodology A cross-sectional study was performed among Saudi males in Tabuk City. A structured interviewing technique based on a questionnaire was used based on the objectives and research questions. Data were collected by well-trained data collectors from the general population in Tabuk City who were randomly chosen in proportion to the city’s population density. A multivariate logistic regression analysis was done to evaluate the variables related to knowledge and awareness in this study. Results This questionnaire was completed by a total of 417 male participants. In the studied group, 86.8% of participants had heard about prostate cancer through friends (59%), TV/radio/newspaper (53.24%), and other health services (41.49%). In addition, around 67.6% of participants knew about the prostate cancer screening test. In addition, 32.4% of participants had no prior knowledge of prostate cancer or a screening test. Conclusions There was a good level of awareness and attitude toward screening methods for prostate cancer (54.7%). Aside from having good knowledge regarding prostate cancer symptoms among males in Tabuk City, all participants with regard to demographic distribution showed a significant level of good knowledge and awareness of screening prostate cancer methods and the necessity of performing regular prostate examinations.


Introduction
The male genitalia includes a tiny accessory gland located close to the lower part of the bladder known as the prostate gland, which undergoes malignant changes in prostate cancer.Proteolytic enzymes are released by the prostate, which weighs around 20 g, into the sperm to aid in fertilization [1].Prostate cancer presents with physical and psychological symptoms that distinguish it.Early on, it is typically asymptomatic, but later on, symptoms including frequency, interrupted flow, nocturia, hematuria, and dysuria appear that are comparable to those of benign prostatic hyperplasia.Hip, spine, or rib discomfort can result from prostate cancer with bone metastasis [2,3].
The World Health Organization reports that prostate cancer incidence and fatality rates, notably in the Arab region, have increased and will likely continue to do so [4].However, it was found that in advanced stages, progression was more common in the Arab region than in the United States [5].The prostate cancer fatality rate in the United States has reduced by 40% since 1990, which is attributable to better screening procedures and treatment [6].Prostate cancer is currently known as the second most common carcinoma in Saudi Arabia among males over the age of 60 years.Between 2001 and 2008 in Saudi Arabia, an age-standardized incidence rate of prostate cancer was anticipated to be 5.1 cases per 100,000 males [7].
Arabic, Eastern, and Asian ethnic groups have different prevalence rates for prostate cancer.The United States and Canada have the greatest incidence rates, followed by Europe.While the incidence rate is lower in Asian countries, especially among Arabic communities, the incidence rate according to age standardization of prostate cancer in the Kingdom of Saudi Arabia was 4.5/100,000 in 2012, with the Riyadh and Eastern regions seeing the highest rates.Compared to Europe and the Gulf, this incidence rate is significantly lower [8].
Although there is no single cause of prostate cancer, several factors can have an impact.These components include age, with men over the age of 50 accounting for 60% of new cases of prostate cancer, while cases in people under the age of 40 are rare.The chance of developing prostate cancer doubles when a family member already has the disease because it can run in families [9].
Race is also an essential issue as the illness is less frequent in Asia and more common in European nations (particularly northern regions of Europe) and North America due to a variety of variables such as lifestyle and food.Indeed, genetic variations can play a significant role, as mutations in a cell's DNA cause the cell to become malignant [9,10].
Of note, the relationship between perfect awareness of prostate carcinoma screening and contradictions is unclear.Male people who decided not to be tested had less significant awareness of prostate carcinoma and a less favorable attitude toward different screening methods [11].This information suggests that educating men about screening might help increase screening rates.Other studies found that once participants were aware of the benefits and expenses of different screening methods, educational interventions decreased their interest in the procedure [12].
Regular checkups for prostate cancer can result in an early diagnosis, reducing the likelihood of negative outcomes; nevertheless, screening practices differ by population.An American study found that hurdles to prostate cancer screening include socioeconomic status, fear, communication between patients and doctors, skepticism of the medical community, and resistance to digital rectal examinations [13].
It is unclear why males refuse to undergo prostate cancer screening.Studies discussing this issue among public people in the Arabic region are rare.The incidence of prostate cancer in developing countries varies significantly from that in the United States and Europe.Additionally, there is no national screening scheme in Arabic countries.More information on the factors that affect attendees is required to alter screening processes.This research analyzed men's awareness and attitudes about prostate cancer and its screening modalities in our region to identify the potential factors that contribute to better prostate cancer screening [14].

Study design
This study was conducted in Tabuk City, Saudi Arabia.The general population's knowledge and awareness of screening for prostate cancer risk factors and symptoms were examined using a cross-sectional survey methodology between May and August 2023.

Study population
This study included all adults 40 years of age and older living in Tabuk City who were willing to participate.Individuals aged less than 40 years, those who had genitalia disease, and all women were excluded.

Sample size
The sample size for this study was determined using the following formula: n = (Z 2 × p × q)/d 2 , where n is the required sample size, Z is the confidence level (standard value of 1.96 for 95% confidence), p is the estimated percentage of the population, q is 1-p, and d is the margin of error (5% or 0.05).We used a prevalence rate of 50% based on previous studies.The minimum sample size required for this study was calculated at 384 participants.We recruited 417 participants in this study.

Sampling technique
This study employed random sampling as its sampling strategy.Participants were chosen at random from the general population of Tabuk City's general center.The city was split into neighborhoods, and participants were chosen from each of them.This approach guaranteed that the sample was representative of the population and that there were enough participants.

Data collection tools
The data were gathered face-to-face using a questionnaire based on the objectives and study questions (see Appendices).The questionnaire was developed in English, and a committee of specialists reviewed it and made changes.To prevent variance in data collection, data collectors were trained on how to Arabize the questions in a session designed specifically for this purpose.To verify its clarity and validity, a pilot study was conducted among 23 people from the target group who were not included in the final analysis.Cronbach's alpha was 0.74, which was acceptable.

Data analysis
SPSS version 28 (IBM Corp., Armonk, NY, USA) was used to analyze the data.Data were compiled using descriptive statistics.The association between knowledge and awareness of screening for prostate cancer risk factors, symptoms, and demographic characteristics was examined using the chi-square test and logistic regression analysis.A p-value ≤0.05 was considered significant.

Ethical considerations
The Institutional Review Board of King Salman Armed Forces Hospital provided ethical permission for this study (approval number: KSAFH-REC-2023-515).All study participants provided verbal informed consent before participating in the study, and the questionnaire was gathered from respondents and analyzed with secrecy while ensuring privacy.

Results
A total of 417 male participants were included in this study, with ages ranging from 40 to over 60 years old.When participants were asked whether they had heard of prostate cancer, there was a non-significant correlation between their responses and the following questions: If yes, what kinds of examinations are you familiar with?(p = 0.160); can prostate cancer only be detected through a prostate exam?(p = 0.164); is the annual screening frequency for men the same as the interviewees' average age?(p = 0.624); should only men with urological symptoms be screened?(p=0.122),what prompted the request for the prostate exam?(p = 0.446); when did you most recently have the test?(p=0.650);have you ever had a PSA performed?(p = 0.248).

Discussion
The cancer that most commonly affects adult men worldwide is prostate cancer, which can be fatal if there is any delay in diagnosis.It is thought to be the second most common type of cancer detected and is a factor in the rising death rate among adult males.Due to their limited awareness of the symptoms and their attitudes toward early screening, studies have shown that older men have a high prevalence of prostate cancer [15].In Tabuk City, Saudi Arabia, this study examined the awareness, attitudes, and prostate cancer screening practices of men.
Studies conducted in Medina, Jeddah, and Makkah in 2022 [7] reported that the overall knowledge of prostate cancer was low at 47.5% and the awareness of prostate cancer screening tests was not known in 80.9%.A study conducted in Riyadh in 2015 [14] found that participants had insufficient awareness of prostate cancer risk factors, and reported that participants were characterized by having poor knowledge of prostate cancer detection where the mean of total correct knowledge was 51.2%.The vast majority of participants in our study (86.2%) had heard of and reported adequate knowledge about prostate cancer risk factors.Additionally, the majority of participants demonstrated an acceptable understanding of the signs of prostate cancer.Most study participants demonstrated good knowledge about prostate cancer screening.
Our results were in line with a study conducted in Oman (2020) [16].The majority of participants reported that they obtained most of their knowledge about prostate cancer through friends (n = 246, 58,99%), followed by TV/radio/and newspapers (n = 222, 53.24%).Participants in this study were more aware of the signs and symptoms of prostate cancer than the general community in Tabuk, which indicated high levels of knowledge, in comparison to populations in other regions of Saudi Arabia and other nations like Jordan and Egypt [17].
Our study group revealed that smoking could be a significant risk factor for prostate cancer (n = 218, 52.3%), which was in contrast to previous studies by Quaife et al. [18] and Al-Fayez et al. [19] on the causal relationship between tobacco and prostate cancer.Our participants' awareness of the risk factors for prostate cancer was greater (n = 300, 71.94%) for family history of the disease and advanced age (n = 273, 65.47%), and earlier investigations confirmed our findings such as the study by Quaife et al. [18].
Regarding demographic parameters, all participants in this study demonstrated appropriate awareness of prostate cancer.Our findings showed that the participants' responses regarding the significance of performing routine prostate exams were as follows: all age groups agreed that performing routine prostate exams is important; regardless of marital status, all groups indicated that performing routine prostate exams is crucial.
All educational levels in the groups demonstrated the significance of undergoing prostate examinations regularly, except those with elementary and no education levels, who responded insufficiently.Regular prostate examinations should be performed, according to data from all occupational levels.A previous study found that participants in all monthly income categories significantly agreed that it is important to undergo prostate examinations on a regular basis, as supported by our findings.

Limitations of the study
The study sample might not be entirely representative of the study community because it was chosen at random, and the findings might not apply to other communities outside of Tabuk City.

Conclusions
The majority of people in Tabuk City demonstrated commendable knowledge and a favorable attitude toward prostate cancer.However, a proportion of the population had a poor grasp, a pessimistic outlook, and an unfavorable opinion of prostate cancer screening and treatments.This emphasizes the requirement for more comprehensive educational activities that support screening behavior and early presentation.
According to this study, a higher level of education is associated with a better comprehension of the causes and signs of prostate cancer.

Table 2
presents the participants' knowledge of prostate cancer symptoms and risk factors.Participants had a good understanding of prostate cancer (n = 362, 86.6%).Friends were the most common source of information (n = 246, 58.99%), followed by other health services (n = 173, 41.49%).The majority of participants demonstrated inadequate knowledge about how to prevent prostate cancer (n = 256, 61.4%), and family history of the disease was the risk factor with the highest frequency (n = 300, 71.94%), followed by age (n = 273, 65.47%) between 40 and 50 years.Age over 50 years old was the group with the highest frequency as the age when they should be more concerned about getting an examination (n = 172, 41.2%).

TABLE 3 : Awareness of participants for prostate cancer screening.
**: p < 0.001 is statistically significant.The chi-square test was done.**: p < 0.01 is statistically significant.The chi-square test was done.*: p < 0.05 is statistically significant.The chi-square test was done.