Colonoscopy screening for colorectal cancer in Egypt: a nationwide cross-sectional study

Colorectal cancer (CRC) is the third most common cancer worldwide and the second most common cause of cancer-related mortality [1]. Survival rates vary significantly according to the disease stage at which cancer was diagnosed. For example, the 5-year survival rate dramatically increases to 90% when patients are diagnosed at an early stage compared to 14% in patients with metastatic stage at presentation [2, 3]. Efforts have, therefore, been made to empower CRC early detection through the implementation of screening programs in different countries. In the United States, such efforts led to a significant reduction in CRC-related mortality [4‐6].

Current guidelines advocate for CRC screening in adults aged 45–75 years using direct visualization methods such as colonoscopy or stool-based tests such as fecal occult blood test (FOBT) [7, 8]. However, participation rates and physicians’ referrals remain a significant challenge despite the enormous efforts put in that regard [9]. For example, nearly 30% of eligible adults in the United States are not compliant with the current recommendations for CRC screening [10]. A study in Hungary reported that a similar percentage of participants did not even hear about CRC screening methods [11]. A third study in the West Pacific Region reported a low level of patient awareness of the disease burden and poor adherence to screening [12]. The frequency of non-compliance is reported to be even higher in developing countries either due to lack of awareness [13], patients’ refusal due to cultural barriers, financial burden [14], or non-referral by healthcare providers [15].

In Egypt, data about the prevalence of CRC are not consistent but it is estimated to rank as the eighth most common cancer diagnosis in some reports [1, 16]. The incidence rate is estimated to be 9.8 per 100,000 cases [17]. However, there is a paucity of relevant studies assessing the current attitudes towards CRC screening and its actual practice. The Egyptian insurance system provides coverage for CRC screening in eligible adults [18] but compliance with standard guidelines remains unknown. It is noteworthy that compliance with other screening programs including breast cancer remains relatively poor [19]. Moreover, we have at least some evidence suggesting that most CRC cases in Egypt are diagnosed in late stages [20] which casts doubts on the current practice of CRC screening without the possibility of reaching definitive conclusions.

In this study, we aimed to evaluate the current practice of CRC screening in Egypt and compliance with the most recent guidelines. Moreover, we aimed to assess the knowledge about CRC screening, explore patients’ attitudes, and investigate potential barriers.

The magnitude of CRC in Egypt is exacerbated by the late diagnosis of cases which is in turn associated with poor prognosis [20]. Our study highlights the low rates of referrals to CRC screening in Egypt, which might be a contributing factor. Moreover, we demonstrate that despite positive attitudes towards CRC screening, low levels of awareness may be the key challenge that needs to be addressed by policymakers and healthcare providers.

Using a nationwide survey, we found that only 2.3% of eligible participants were referred for CRC screening. This rate is much lower than that reported in other parts of the world. For example, in the United States, more than two-thirds of the eligible adults are currently undergoing screening. In Canada and France, 37% and 59% of eligible adults had undergone screening, respectively [10, 22, 23]. However, our results are comparable to those of other studies from the Middle East, including Lebanon (15%) and Saudi Arabia (8.6%) [13, 14]. Similarly, low rates of participation have been reported in other developing countries including India (1.5%) and Indonesia (3%) [12]. The low participation rates in our study could be attributed to a lack of knowledge regarding CRC risk factors and screening guidelines. Our findings also revealed that referral rates were higher in participants who had discussions with their physicians about cancer screening in general or CRC screening in particular. Personal experience with someone diagnosed with or deceased from CRC was also associated with higher referrals for screening.

Among the surveyed participants, we found that only 3.2% of participants had good knowledge of CRC screening guidelines, indicating notably low awareness among the Egyptian population. In comparison, other countries in the Middle East and Europe had higher levels of awareness. For example, 38.3% and 45% of participants in Lebanon and Saudi Arabia, respectively, had good knowledge about CRC screening [24, 25]. Studies in other parts of the world have also reported similarly fair levels of knowledge about CRC screening [11, 12]. This disparity might be attributed to the lack of accessible knowledge resources and awareness campaigns.

In our study, many factors have been associated with participants’ level of knowledge, including educational level, income, residency, and personal experience with CRC. These findings are consistent with prior research as individuals with higher levels of education may have a better understanding of medical concepts, while those with personal experience may have a greater appreciation for the importance of screening [26, 27]. Previous discussions with physicians about CRC or CRC screening have been shown to significantly improve the level of awareness. This aligns with previous research as physicians can provide individuals with personalized information about screening that is more likely to be trusted and acted upon [28]. Despite the low level of knowledge observed in our study, over 80% of the participants wanted to obtain more information about CRC screening showing the value of addressing existing knowledge gaps and enhancing awareness among the Egyptian population.

Most participants exhibited a positive attitude towards CRC screening (66.7%). Almost two-thirds of our participants (62.6%) were willing to undergo CRC screening if recommended by their doctors, which is similar to data from Saudi Arabia and Lebanon [14, 24]. A high educational level or knowledge of someone diagnosed with CRC had a favorable effect on our participants’ attitudes. This association has been previously reported in another study [29]; and can be linked to realizing the hazards, comorbidities, and crucial role of early detection in CRC prognosis. Interestingly, our 10-min questionnaire increased willingness to undergo screening by more than 60%. This would highlight the link between awareness and attitudes; and support calls for national awareness campaigns that could probably improve attitudes and compliance. However, this does not necessarily imply a direct causal impact of the questionnaire but rather suggests that the information contained in the questionnaire could have contributed to changing participants' perceptions about the importance of CRC screening.

Financial burden was by far the most reported barrier for not undergoing CRC screening followed by fear of results and low knowledge about CRC screening. This could be related to the overall economic state in Egypt. In comparison, fear of results and lacking of knowledge about CRC screening were the most important barriers in Saudi Arabia [13]. In our study, fear of results was higher among participants with higher levels of education and those with prior disease background either through discussions with their physicians or knowing someone diagnosed with the disease. This finding may be attributed to a greater understanding and knowledge of the disease and its potential consequences.

Our study had several limitations. First, we used a convenience sampling method to recruit participants from outpatient clinics at university hospitals, which might not be optimum. However, the large number of responders should improve the generalizability of results. Second, the analysis was constrained by the small number of participants who were referred for CRC screening. Therefore, associations with other parameters that were explored as secondary endpoints should be interpreted with caution. Moreover, surveying attitudes of participants who often visit healthcare facilities may be influenced by their health-seeking behavior. Additionally, explaining CRC screening just before asking participants about their attitudes may have not fully eliminated the impact of knowledge deficiency. Furthermore, we didn’t assess the awareness of CRC symptoms and its potential associations with our study outcomes, which could be further explored in future studies. Lastly, physicians’ perspectives on referral rates and potential barriers to CRC screening were not explored. This would be an area of interest for future studies and would complement data that we reported from patients’ perspectives. Despite these limitations, our study provides the largest to date assessment of colonoscopy screening practice in Egypt. This should help inform decision makers about possible challenges that may need to be addressed.

Despite the positive attitude, there is deficient knowledge about CRC screening among eligible participants in Egypt. This has probably resulted in low compliance with current CRC screening guidelines. Implementing an organized national screening program may help to increase public awareness and promote CRC screening practice in the community.