Keywords
colorectal cancer - screening - prevention - risk factor - knowledge
Introduction
Colorectal cancer (CRC) is the most prevalent malignant neoplasm in the gastrointestinal
tract and one of the most prevalent malignant neoplasms worldwide.[1]
[2] Having a high propensity for metastasis and significant aggression, this type of
tumor primarily impacts individuals over the age of 50.[1]
The onset of CRC decreases significantly with the adoption of healthier lifestyles,
which are associated with a multitude of risk factors.[3] Hence, engaging in regular physical activity, increasing fiber consumption, decreasing
carbohydrates, alcoholic beverages, red meat, sodium, ultra-processed foods, and overall
caloric intake appear to provide a preventive influence against the development of
tumors.[4]
[5] Conversely, the presence of polyps and prior inflammatory diseases (e.g., ulcerative
colitis and Crohn disease) are risk factors for colorectal cancer, while the transmission
of genetic mutations within the family is associated with this condition.[2]
[4]
[5]
Colorectal cancer is characterized by a significant mortality rate; thus, the prevention
of this disease is critical.[4] This preventive measure is linked not only to lifestyle modifications but also to
heightened public awareness concerning risk factors and screening techniques.[3] Finding this subtle neoplasm early is often difficult because symptoms do not appear
until the cancer has spread significantly. Knowledge of the signs improves the prognosis
because it allows for an earlier diagnosis.[4]
[5]
Furthermore, screening methods are extraordinarily effective at reducing the morbidity,
mortality, and treatment expenses associated with advanced stages of CRC.[6] Early-stage tumors and precancerous lesions can be identified using screening procedures
such as sigmoidoscopy, fecal occult blood testing, and colonoscopy.[4]
[5]
Despite the considerable prevalence and fatality rate associated with this malignancy,
societal awareness regarding CRC prevention and screening remains limited.[6] The general public's lack of awareness regarding risk factors and warning signs
remains a significant obstacle to early detection, morbidity reduction, and mortality
mitigation.[3]
[4]
[7]
In light of this epidemiological situation characterized by a high incidence of CRC
and limited dissemination of information regarding the disease, the purpose of the
present research is to assess the level of knowledge that employees at a reference
cancer center have regarding CRC screening and prevention. By implementing this methodology,
we will have the capacity to evaluate the effectiveness of the information distribution
concerning CRC in our local community. This will enable us to devise initiatives that
promote the spread of knowledge of this malignancy.
Materials and Methods
Study Design
An observational, cross-sectional study was conducted in a public oncological center
located in Salvador, Bahia, which is a health center dedicated to the specialized
care of patients diagnosed with cancer. Sociodemographic and evaluative inquiries
pertaining to the prevention and screening of CRC were incorporated into a questionnaire
utilized for the analysis. Personnel affiliated with the health center who were a
minimum of 18 years old were included, regardless of gender. Conversely, employees
who were illiterate were not eligible.
Instruments for Data Collection and Questionnaires
The data were gathered via in-person administration of a structured electronic questionnaire
(Google Forms, Google LLC., Mountain View, CA, USA) that comprised evaluative and
sociodemographic inquiries pertaining to the prevention and screening of CRC. Data
collection was conducted from 8 a.m.to 5 p.m., 5 days per week, during business hours.
Participants who satisfied the inclusion criteria and expressed interest in taking
part in the research were informed about the study and directed to a designated area
to respond to the inquiries in private and one-on-one. To ensure the preservation
of confidentiality, the researcher refrained from becoming involved and solely extended
aid upon the interviewee's request. The participant completed the survey solely after
affixing their signature to the Informed Consent Form (ICF). Messages or email invitations
to the form (e-mails containing a single sender and recipient) were promptly dispatched
to the volunteers following their completion of the ICF. The questionnaire did not
allow for the omission of answers. This safeguard kept questionnaires from being filled
out incorrectly.
Prior to administering the questionnaire, the research team had not established any
prior relationships with the interviewees, and they were not provided with any information
regarding the prevention or screening of colon and rectal cancer. The study received
approval from the Ethics Committee of the Health Department of the State of Bahia
(CAEE, 67505623.9.0000.5606).
In addition to knowledge of risk (family history, smoking, alcoholism, personal history
of inflammatory bowel disease [IBD], inadequate diet, and sedentary lifestyle), preventive
factors (maintenance of a healthy diet, regular exercise, and medical checkups), screening
techniques (fecal blood, sigmoidoscopy, and colonoscopy), warning signs (tenesmus,
loss of weight for no apparent reason, alteration in intestinal rhythm, abdominal
pain, and the presence of blood in the stool), and recommended start dates for screening
(≥ 45 years), the following variables were assessed: occupational domain, gender,
age, schooling, and length of service in the organization.
Data Analysis
The SPSS for Windows software, version 14.0 (SPSS Inc., Chicago, IL, USA) was used
to develop the database and conduct descriptive and analytical statistical analyses.
The means and standard deviations were used to represent continuous variables that
followed a normal distribution, while the median and interquartile range (IQR) were
applied to represent non-normally distributed variables. Categorical variables were
expressed as absolute frequencies and percentages. Using descriptive statistics, graphical
analysis, and the Kolmogorov-Smirnov test, the normality of the numerical variables
was confirmed.
The sample size was estimated a priori based on the difference between group proportions
(50% and 70% in relation to knowledge about colorectal cancer screening). Therefore,
adopting an α value of 5% and a statistical power (1-β) of 90%, it was necessary to
apply 266 questionnaires.
To assess the relationship between the variables under investigation, the Mann-Whitney
U test or the student t-test was utilized, contingent upon the variables' normality. The Pearson or Spearman
correlation coefficient and the Pearson chi-squared test were applied to determine
the relationship between categorical and numeric variables, respectively. The statistical
significance level was p < 0.05.
Results
Simple Characterization
The study sample comprised 266 employees, with a median age of 45 (53.00–35.75). A
significant proportion of the employees were female (76.3%) and had a higher level
of schooling (54.9%). Additionally, it was noted that a significant proportion of
the participants were employed in the administrative and general services sectors
(54.1%) and possessed over a year of experience at the health center (74.1%). ([Table 1])
Table 1
General characteristics of the sample of employees of the Centro Estadual de Oncologia
(CICAN), Salvador, BA, 2023
|
Variables
|
Employees
N = 266
|
|
Age (ME/IQR)
|
45/53.00–35.75
|
|
Gender N (%)
|
|
|
Male
|
63 (23.7)
|
|
Female
|
203 (76.3)
|
|
Education N (%)
|
|
|
Elementary/High school
|
120 (45.1)
|
|
Higher education
|
146 (54.9)
|
|
Occupation area N (%)
|
|
|
Health services
|
122 (45.9)
|
|
General and administrative services
|
144 (54.1)
|
|
Working time N (%)
|
|
|
For 1 year
|
69 (25.9)
|
|
For more than 1 year
|
197 (74.1)
|
Abbreviations: IQR, interquartile range; Me, median; N, number.
A significant proportion of the 63 men interviewed (74.6%) were employed in services
other than health (general and administrative), whereas 106 (52.2%) of the 203 women
interviewed were directly employed in health services. This indicates that women held
a greater number of positions associated with patient care (106 [52.2%] versus 16
[25.4%], p < 0.001). Additionally, most of the women (122 women, 60%) and employees (94 employees,
77%) who were directly involved in health services ([Graph 1]) had higher levels of schooling.
Graph 1 Level of schooling of women and employees working in health services.
CCR Knowledge Assessment
Consensus was reached regarding the definition of CCR by most of the respondents (87.2%).
In relation to CRC risk factors, 110 (41.4%) participants demonstrated awareness of
all 6 factors outlined in the questionnaire, whereas 19 (7.1%) did not identify any
of them. A total of 220 (82.7%) participants were able to identify at least half of
the risk factors. Moreover, lack of awareness regarding personal history of inflammatory
bowel disease was the least acknowledged risk factor (167 participants, 67.6%), whereas
inadequate nutrition was the most recognized (229 participants, 92.9%).
A total of 188 (70.7%) employees demonstrated awareness of all 3 CRC preventive factors
that were included in the questionnaire. Conversely, 18 (6.8%) employees failed to
recognize any of the factors. Moreover, regular medical appointments were the subject
of the greatest amount of knowledge (241 employees, 97.2%) among the group of 248
employees who possessed at least 1 preventive factor.
It was seen that most of the sample (149 employees, 56%) knew all 5 warning signs
of CRC covered by the questionnaire, and 22 (8.3%) employees were not aware of any
of them. A total of 212 (79.7%) individuals identified 3 or more signs. The presence
of blood in feces was the most recognized by 237 (97.1%) employees of the group with
at least one alarm signal knowledge (244 employees, or 91.7%), whereas tenesmus received
the least recognition (170 employees, 69.7%). ([Graph 2]).
Graph 2 Recognition of each warning sign for colorectal cancer by CICAN employees.
As for CRC screening, it was observed that 154 (57.9%) employees were duly informed
of the 3 primary tests employed for this objective, whereas 29 (10.9%) employees failed
to comprehend the implementation of any of them. Conversely, a minimum of 1 method
was understood by 237 (89%) employees. Colonoscopy was the most widely recognized
screening test (98.7%), whereas sigmoidoscopy was the least recognized (74.7%). ([Graph 3])
Graph 3 Recognition of each colorectal cancer screening technique by CICAN employees. Abbreviation:
FOBT, Fecal occult blood test.
With respect to employee satisfaction with their level of knowledge concerning CRC,
50% of the participants expressed satisfaction. But in relation to the presence of
educational initiatives concerning CRC, a majority (52.6%) of the respondents indicated
that the cancer center did not offer any information. Although the health center does
not provide formal CRC education, most of the employees with more than 1 year of experience
at the cancer center reported learning about CRC during their professional activity
[83 (42.1%) × 17 (24.6%), p = 0.001)].
Even if they did not have risk factors, most patients aged 45 or older (83.65%) were
aware that individuals in their age group should begin CRC screening. Conversely,
employees aged 45 years or older and those younger did not differ in their understanding
of the optimal age to begin screening (112 [83.6%] versus 109 [82.6%], p = 0.729).
Employers with a greater level of schooling had a greater understanding of the CRC
concept than those with a lower level of schooling (139 [95.2%] versus 93 [77.5%],
p = 0.001). Regarding inquiries about risk factors, prevention, warning signs, and
screening, it was indisputable that healthcare employees recorded a higher proportion
of accurate responses. ([Table 2])
Table 2
Comparison between employees of health services and general and administrative services
regarding the total number of correct answers regarding risk factors, prevention,
warning signs and screening for colorectal cancer
|
Variables
|
Health services
|
General and administrative services
|
p-value
|
|
N = 122
|
N = 144
|
|
|
Risk factors
|
(ME/IQR)
|
6 (4–6)
|
5 (2–5.75)
|
< 0.001+
|
|
Prevention
|
(ME/IQR)
|
3 (3–3)
|
3 (2–3)
|
< 0.001+
|
|
Alarm signals
|
(ME/IQR)
|
5 (5–5)
|
4 (1–5)
|
< 0.001+
|
|
Screening
|
(ME/IQR)
|
3 (3–3)
|
2 (1–3)
|
< 0.001+
|
Abbreviations: IQR, interquartile range; Me, median; N, number.
Note: +Mann-Whitney test.
Discussion
In the present study, it was seen that most of the employees had a good degree of
information about the concept, risk factors, prevention, warning, signs and screening
of CRC. Only a small number of respondents were unaware of the pathology. In addition,
it was observed that the best-informed employees had higher level of schooling, worked
directly in the health sector, and had been working for more than 1 year at the cancer
center.
Most personnel asserted their understanding of the CRC concept. The primary factor
contributing to this outcome is the occupational environment of these individuals,
which is a reference cancer center where they are routinely exposed to cancer cases,
including rectal and colon cancer. Additionally, it is critical to emphasize that
the widespread recognition of this pathology's concept is aided by its high incidence;
it is the second most prevalent cancer-related death and the third most prevalent
malignant disease worldwide.[8]
At least half of the CRC risk factors discussed in the questionnaire were recognized
by most of the respondents. The least recognized risk factor in this investigation
was inflammatory bowel disease (IBD), while inadequate nutrition was the most widely
acknowledged. Lifestyle has a direct impact on the development of colorectal neoplasia,
as is well established in the scientific literature. Risk factors for colon and rectal
tumors include a family history of CRC and IBD, excessive alcohol consumption, smoking,
a sedentary lifestyle, and a poor diet.[5]
[8]
[9] Six risk factors that were discussed are also prevalent in other malignancies; thus,
they are already pervasive in society. As a result, it is important to note that the
result in question might not be entirely attributable to knowledge of CRC. Patients
with IBD have a 60% greater likelihood of developing CRC than the general population,
which must be emphasized in this analysis.[8] As the association between IBD and colon and rectal cancer is the least recognized
risk factor by the staff, this is a concerning matter, as early screening is even
more necessary in its presence.[10]
[11]
The findings of the present study indicated that a significant proportion of employees
possessed knowledge pertaining to the three preventive factors examined in relation
to CRC prevention. A greater protection against the development of numerous neoplasms,
including those of the colon and rectum, is assured by adopting healthy lifestyle
practices such as good nutrition, regular exercise, and medical checkups.[6]
[9]
[12] Given its high mortality rate and substantial metastatic potential, prevention should
be the primary focus, given the extremely aggressive nature of this neoplasm.[4] The most widely known preventive measure for CRC among employees in the current
study was consistent medical consultations. This result may be attributed to the ongoing
exposure of staff members to health concerns at the facility, where the physician
assumes a pivotal role in the prevention, diagnosis, and treatment of malignancies.
This exposure may be characterized by a direct or indirect connection.
Likewise, most of the employees, demonstrated awareness of all five risk indicators
for CRC as outlined in the survey. Because it is an insidious neoplasm whose symptoms
typically manifest in more advanced stages, delaying diagnosis, this analysis is crucial.
Hematochezia, which was the most recognized alarm sign among those interviewed, merits
special attention due to the fact that painless bleeding can foretell the emergence
of other symptoms of CRC within 2 to 3 years.[13] As a result, an earlier diagnosis and a more favorable prognosis can be achieved
by promptly identifying the presence of blood in the stool as an indication of CRC
prior to the manifestation of other symptoms. Tenesmus, by contrast, was the least
known warning sign. The observed outcome may be attributed to the general population's
awareness of the correlation between serious pathologies and blood, while tenesmus
is a symptom that is considered more subjective in nature.
Regarding CRC screening, it is known that, in regions in which screening is effective
and widespread, there is a proven reduction in the incidence and mortality rates of
this neoplasm.[5]
[12]
[14]
[15] In this regard, early detection of the pathology is critical, as any delay in diagnosis
substantially increases morbidity, mortality, and treatment costs.[6] It was discovered that a considerable proportion of the personnel involved in this
study had acquired knowledge regarding all three screening techniques that were examined
in the survey. Once more, this result may be attributed to the employment of the interviewees
at an oncology center.[12] Furthermore, it is essential to underscore that the participants ranked colonoscopy
as the most widely recognized screening test. This methodology is considered the standard
for CRC screening on account of its ability to conduct biopsies of early-stage tumors,
detect and excise precancerous lesions, and, thus, have a direct bearing on a more
favorable prognosis.[10]
[11] The preference for the examination as the principal method of screening could potentially
be a factor in its heightened acknowledgment among personnel. Nevertheless, sigmoidoscopy
was the least recognized technique in this regard when compared with the others. This
could be attributed to the fact that colonoscopy can detect proximal lesions, thus
exerting a more significant impact on the reduction of incidence and mortality. Furthermore,
the analysis of latent blood in feces requires less invasive techniques. These advantages,
relative to sigmoidoscopy, could potentially explain a fraction of the increased public
consciousness surrounding them.[12]
Moreover, it is established that screening for colon and rectal cancer should begin
at age 45 for individuals devoid of major risk factors, including a significant family
history and/or prior IBD.[10]
[11] No significant disparity was identified between individuals aged 45 or older and
those younger regarding their awareness of the optimal age to initiate screening.
Younger employees, who fall outside the optimal age range for screening, may know
as much as their older counterparts due to the recent proliferation of information
and the accessibility of this subject through social media platforms, which enable
knowledge to transcend age boundaries. Additionally, it is critical to emphasize that
the incidence of CRC tends to rise among younger populations.[13]
[14] To reduce rates, therefore, it is critical to distribute information regarding screening
throughout all age groups.
An analysis was conducted to determine the extent to which the health center lacked
information pertaining to CRC prevention and screening, with over half of the staff
indicating that this information was unavailable. This result is unexpected given
that, as an oncology center, employees and patients should be well informed about
CRC through educational initiatives. Displaying information in a more accessible manner,
such as through the use of posters, leaflets, or brief lectures, would be ideal from
this vantage point. Conversely, among those who had been employed by the company for
over a year, a greater proportion of staff members reported having acquired knowledge
of CRC at the health center. Additionally, it was observed that personnel employed
directly in health services possessed a more extensive understanding of the neoplasm
in comparison to their counterparts in the administrative and general sectors. This
result suggests that individuals who have been employed for a longer period of time
and have a direct connection to the healthcare industry may have had greater exposure
to CRC cases and gained knowledge from them on a daily basis. Consequently, employees
with limited tenure at the health center and prior experience in other industries
were unable to gain sufficient exposure to actual cases and were thus unaware of the
malignancy at the establishment due to the lack of disclosed information. Furthermore,
it is crucial to emphasize that a significant proportion of health sector employees
possess advanced degrees. This suggests that they were afforded more educational opportunities
prior to their employment at the health center and could have potentially responded
to most of the inquiries regarding CRC by utilizing their prior knowledge.
Furthermore, it was disclosed that personnel possessing an advanced degree were more
knowledgeable regarding colon and rectal cancer in comparison to their less educated
counterparts. As a result of their increased understanding of the pathology, this
group tends to have lower incidence, morbidity, and mortality rates associated with
CRC. Moreover, they are more adept at identifying warning signs, risk and prevention
factors and initiating screening at the appropriate age. Statistical data demonstrates
that as the Human Development Index (HDI) of a given region rises, there is a corresponding
decline in both the incidence and fatality rate of colorectal tumors.[15] This finding serves as a significant indicator of social inequality, as those with
limited educational opportunities have a higher propensity to experience illness.
Overall, it was found that over 50% of the interviewees possessed knowledge of at
least a substantial portion of the inquiries pertaining to the concept, risk factors,
prevention, warning signs, and screening of CRC. Subsequently, to advance the democratization
of information regarding this neoplasm, the health center must disseminate information
regarding CRC prevention and screening in a lucid and expository fashion, whether
via lectures, pamphlets, and posters. This ensures that information is accessible
to all individuals, including those lacking undergraduate degrees or direct experience
in health-related fields.
Because a significant portion of the sample also possesses academic training in the
healthcare field and deals with cancer on a daily basis, it is crucial to emphasize
that the current study has some limitations and may not accurately represent the level
of knowledge of the general population. Furthermore, it is widely acknowledged that
the general public still has limited access to information regarding colon and rectal
cancer, rendering it a potentially fatal disease that is often detected too late.[3]
[4]
[6] As a result, it is critical to increase public awareness regarding CRC. Equipped
with this knowledge, individuals can take proactive measures to mitigate modifiable
risk factors, identify warning signs with greater ease, and conduct screening at an
earlier stage. The result will be an increased propensity for CRC prevalence, morbidity,
and mortality rates to decline.[3]
[4]
Conclusion
Employees at a reference cancer center have a satisfactory level of knowledge about
CRC prevention and screening, including the ability to recognize risk and prevention
factors, warning signs, and screening techniques, particularly employees who work
directly with patients, and those with a higher level of schooling. This finding also
highlights the need for greater dissemination of CRC information, particularly among
those with lower levels of schooling.
